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When disaster strikes, will you be ready?

Nielson, Mary Hugo DNP, APRN, ANP-BC, SANE-A

doi: 10.1097/01.NURSE.0000526891.17929.d4
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Whether natural or man-made, disasters can occur anywhere, at any time. As outlined here, know, follow, and practice the plan so you and your colleagues can respond confidently in an emergency.

Mary Hugo Nielson is an assistant professor at Western Connecticut State University in Danbury, Conn.

The author has disclosed no financial relationships related to this article.

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YOU'RE AT THE NURSE'S station when you hear the overhead page for a disaster. You continue what you're doing as you wait for the next announcement, expecting to hear that this is a drill or an error. Again, you hear the overhead page stating your hospital is in disaster mode. You see a few physicians, a resource nurse, and a respiratory therapist run for the stairs. Your nurse manager tells you there was a big explosion in town.

Just at that moment, the command center calls and wants to know your staff-to-patient ratio and how many RNs and unlicensed assistive personnel your unit can send to the ED. Do you know your role in a disaster?

Knowing your hospital's disaster plan is key to surviving what could potentially be a very long day, week, or weeks. One of the goals of Healthy People 2020 is preparedness to improve the nation's ability to prevent, prepare for, respond to, and recover from a disaster. The goal is to empower individuals and ensure awareness.1 To be prepared at all times requires vigilance and familiarity with your institution's disaster plan. As discussed here, this is best accomplished by developing, maintaining, and practicing the plan at work.

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Many faces of disaster

Disasters come in many forms, sizes, and durations. A disaster is defined as a sudden event that disrupts the function of a community and inflicts great loss (human, material, environmental, economical).2 Disasters are classified as either natural disasters (flood, tornado, earthquake) or manmade disasters (explosion, chemical spill, mass casualty event). A disaster can also be a cyber-attack that affects your entire healthcare system, or an infectious disease that overwhelms your community, hospital, and services for several days or weeks.3

Disasters may cause a surge of patient flow, as with an explosion, or a gradual influx of patients, as seen with illness such as seasonal influenza. Disasters can create difficulties for your commute to and from work; disasters can also leave you stranded at work or at home. Whatever the disaster may be, you must plan for the worst-case scenario; emergency management and planning will give you the peace of mind you require to function during a disaster.4

The effects of a disaster on the community include human loss, material loss, structure loss, and environmental loss, which last well beyond a few days. Some of these disasters affect water supply, electricity, the ability to get food and supplies, and the economy. Disaster preparedness education isn't included in most nursing school curricula, and training that addresses both clinical care and system issues should be provided to all healthcare professionals.5 Understanding the basics of emergency management such as disaster mitigation and preparedness is vital in preventing loss of life and minimizing economical and structural losses.

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Emergency operations management

All institutions are either required or encouraged to have emergency operations plans, and personnel with a direct role in emergency preparedness are required by the Homeland Security Presidential Directive (HSPD 5) to have National Incident Management Systems training. (See The National Incident Management System.) Understanding some of the key components of emergency management and the concepts of an emergency operation plan is vital for any professional nurse working today.

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Disasters affect healthcare and community health systems resources, organizational structure, and finances. The impact of a disaster affects a hospital in cycles. The first cycle can disrupt hospital functions within 15 to 30 minutes of the disaster.8,9 Patients arriving in the first cycle are usually the walking wounded and the first to present to the hospital.8 The second cycle includes more critically ill patients and can last hours to days as victims are extricated from the scene.8 The third cycle can affect hospital functions for several days or weeks, as these are patients with untreated acute or chronic conditions that will need treatment for their illness.8

A disaster creates a great demand for resources and personnel, and job roles and responsibilities must shift to manage the overload. Resources may be exhausted quickly, depending on the disaster. As an example, consider the use of personal protective equipment for a biological disaster or dressings and supplies for a trauma-related disaster. Communication of these needed resources is vital to an Incident Command Center (ICC); however, it's often an afterthought, and supplies run out quickly. The exact resources needed must be communicated clearly via telephone or radio to the designated person in the ICC. Resources such as personnel; equipment such as noninvasive BP monitors; and supplies such as bandages, I.V. tubing, and solutions must be specifically requested.10

The ICC is a location where a group of institution employees will gather during a disaster. This group of employees will oversee the needs of the institution during the disaster.9 The ICC staff will make overall decisions regarding the function and functionality of the institution during a disaster.9 Specific roles within the ICC are incident commander, operations officer, planning officer, and logistics officer.9 The ICC can have minimal staff for small disasters or a larger staff for larger disasters.9

Another consideration is the effect that a disaster can have on personnel. Healthcare staff will become fatigued, after only a few labor-intensive, stressful hours; knowing if there's a plan for breaks and rest periods as well as relief staff will give staff the peace of mind needed during a disaster.

Finally, consider patient surge. What's the hospital's surge capacity plan? How much ability does the hospital have to increase and conserve resources? The Agency for Healthcare Research & Quality states that hospitals should be prepared to operate for up to 4 days without outside help during an emergency.11

Emergency management, which includes the actions or steps taken to decrease the potential loss during a disaster, includes four stages: mitigation, preparedness, response, and recovery. The mitigation stage involves taking preemptive measures to eliminate or reduce the risks and impacts of a disaster before it occurs. Preparedness includes taking measures to prepare for the effects of a disaster. In the response stage, steps are taken to save lives and prevent further damage. The final stage is recovery; it's in this stage that events and actions return to normal. Refer to Stages of emergency management for further detail.

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After mitigation, practice

Healthcare institutions along with public and community entities have already completed the mitigation stage of emergency planning. This step is required to complete and develop the plan for preparedness. The mitigating step needs to be reviewed and updated periodically. A systemwide plan needs to be practiced with a mitigating eye to identify resources or systems that had changed; this is how the disaster plan gets updated on a larger scale.

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Table

After mitigation, is preparedness; The plan needs to be practiced. This practice includes simulation of the response and recovery stages of a disaster. Hospital personnel are required to practice emergency response to disasters.14 It's during this practice that nurses learn and understand their roles and responsibilities.

Regardless of where you may work, the roles of a professional nurse include planning, managing, and responding to patient surge, surveillance, and assisting with vulnerable populations.15 As a professional nurse, you need to locate your institution's emergency operation plan, identify the ICC's structure, and identify your role and responsibilities in a disaster. It's pivotal to know the plan, the command structure (who's in charge), and the key components of disaster preparedness. The disaster plan will identify, list, and describe your specific responsibilities, and identify the person to whom you directly report.

It's also important to identify your institution's and unit's responsibilities and duties during a disaster. Will your institution provide all service lines or have a designated function? For example, in the case of an infectious disease outbreak such as smallpox, would your organization be a primary provider for all patients with smallpox or would your institution care for all other patients within the community? Finally, professional nurses will maintain training in basic life support and advanced cardiovascular life support.5

Identifying communication techniques, keeping and maintaining open lines of communication, and learning to use alternate communication methods also need to be considered. You'll need to understand how the communications will work inside your institution as well as communicating to the outside. With an extended power outage, for example, will you use radios in the hospital to communicate your needs, or will you have runners to deliver your messages? Once you know the equipment you may have to use, locate procedural manuals, if appropriate, and practice using that equipment.

Train and practice the plan, and participate in all disaster drills demonstrating different scenarios with different equipment. This will keep you up-to-date on seldom-used equipment and procedures.

Review the plan every 6 months. Take 15 to 30 minutes to review the roles, action plans, policies, and procedures. Put the plan into practice; talk about the plan with coworkers at lunch. Role playing and routine drills will ensure that the disaster plan is up to date and functional.

Lastly, understand that things won't be normal and this will be a very stressful time that pushes people to their limits; flexibility is important to long-term survival.

Ethical, legal, and safety concerns inevitably arise during a disaster. These include having to work with limited supplies and medications, caring for a patient population that you may not be familiar with, and being deployed to work in an unfamiliar unit or service area.5

Nurses must be professionally and personally prepared for a disaster by knowing their nurse practice act and their scope of practice in a disaster.12 Hospitals should have written policies in place regarding nurse responsibilities during a disaster that protect RNs acting in good faith from charges of negligence or malpractice.16

Returning to normalcy after a disaster may take some time. Assisting your institution or local organizations to help minimize illness and injury in the community should be the next step to normalization. It will take time to rebuild a community. Nurses should participate in the rebuilding, offering insight and suggestions to support a successful recovery.

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REFERENCES

1. Healthy People 2020. Preparedness. 2015. http://www.healthypeople.gov/2020/topics-objectives/topic/preparedness.
2. International Federation of Red Cross and Red Crescent Societies. What is a disaster? 2013. https://http://www.ifrc.org/en/what-we-do/disaster-management/about-disasters/what-is-a-disaster.
3. Krisik KM. You can't Band-Aid disaster preparedness. Health Manag Technol. 2015;36(4):32–33.
4. Chaffee MW. Disaster Care. Making the decision to report to work in a disaster: nurses may have conflicting obligations. Am J Nurs. 2006;106(9):54–57.
5. Hunt RC, Kapil V, Basavaraju SV, Sasser SM, McGuire LC, Sullivent EE. Updated in a Moment's Notice: Surge Capacity for Terrorist Bombings 2010. Atlanta, GA: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention; 2010.
6. Federal Emergency Management Agency FEMA. The NIMS integration Center. FY 2006 NIMS training requirements. 2005. http://www.fema.gov/pdf/emergency/nims/06_training.pdf.
    7. Federal Emergency Management Agency (FEMA). National Incident Management System. 2017. https://http://www.fema.gov/national-incident-management-system.
      8. Hughes RT, Trantham P. When disaster strikes, humanity becomes our patient. Perm J. 2011;15(3):e118–e122.
      9. Powers R. Evidence-based ED disaster planning. J Emerg Nurs. 2009;35(3):218–223.
      10. SUNY Downstate. Incident Command Center. https://http://www.downstate.edu/emergency_medicine/pdf/KCHCSection02.pdf.
      11. Agency for Healthcare Research and Quality. Common definitions and reverse triage can help hospital planners meet surge capacity demands during emergencies. 2009. http://archive.ahrq.gov/news/newsletters/research-activities/aug09/0809RA20.html.
      12. Federal Emergency Management Agency (FEMA). Mitigation. 2017. https://http://www.fema.gov/what-mitigation.
      13. Ohio Emergency Management Agency. The four phases of emergency management. 2017. http://ema.ohio.gov/Documents/COP/The%20Four%20Phases%20of%20Emergency%20Management.pdf.
        14. The Joint Commission. Joint Commission Perspective. Requirements for emergency management oversight. 2013. http://www.jointcommission.org/assets/1/18/JCP0713_Emergency_Mgmt_Oversight.pdf.
        15. National Advisory Council on Nursing Education. Challenges facing the nursing workforce in a changing environment. 2009. https://http://www.hrsa.gov/advisorycommittees/bhpradvisory/nacnep/Reports/seventhreport.pdf.
        16. American Nurses Association. ANA issues brief: who will be there? Ethics, the law and a nurse's duty to respond in disaster. 2010. http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/Issue-Briefs/Disaster-Preparedness.pdf.
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