Editor’s note: This article is an overview of disaster preparedness lessons that have been learned from the Florida experience, and our southeastern states. Though Alfasano’s experience has been culled from hurricanes, she recognizes the importance of having a strong “all hazards” approach.


       What exactly is a disaster? The American Red Cross’ definition is that “A disaster is an occurrence such as an ice storm, hurricane, tornado, flood, high water, wind driven water, tidal wave, earthquake, drought, blizzard, pestilence, famine, fire, explosion, volcanic eruption, building collapse, transportation wreck, or other situation that causes human suffering or creates human needs that the victims cannot alleviate without assistance”. Potential disasters could also include the pandemic flu and chemical or biological warfare. Sadly, we realize our world is changing and we are vulnerable in new and emerging ways.
       In Florida, since 2004, we have experienced 9 hurricanes, 7 tropical storms and a recent wildfire. During 2004, we had 2 hurricanes hit within 8 miles of one another, just 3 weeks apart. We have learned that in a disaster event we are starved for communication. State and community relationships are key long before a disaster hits, and we must plan to function as though we are in isolation. Providers must be ready to manage the care of their resident population, and also extend support to other facilities and members of the community. Provider actions include accepting residents from your community and the expansion of emergency medical care. It might also entail the evacuation of residents and staff from dangerous areas. Unfortunately, we discovered during Katrina that even the evacuation could be a vulnerable process. We need to ensure that the disaster response systems in our communities are prepared to triage emerging healthcare needs, and provide for a diverse population of vulnerable long-term care residents.
       Over the past two years, Florida Health Care Association has convened an annual nursing home summit for the Southern Coastal states. This event has been convened by the Florida Health Care Association with funding by the John A. Hartford Foundation, American Health Care Association, AARP, and the University of South Florida’s Center on Aging. The summits have created a venue for lessons learned dialogue and the development of a comprehensive planning and response plan.
       The summits emphasize the importance of establishing model relationships in our communities, and at state and national levels. Disaster Management is a local experience that needs to intersect with long-term care provider networks. It is essential that providers establish communication and support systems through local and state Emergency Operations Centers, also referred to as EOC’s. Key relationships must be facilitated and fostered before you need them. In Florida, FHCA, our healthcare association established a seat at state and local ESF-8’s. ESF-8’s provide emergency support functions for “public health and medical services”. Affiliation helps to ensure that there is a clear understanding of the complex care that is managed in LTC, and what the facility plan is for either evacuation or sheltering in place.
       Here are a few of the areas the summits have brought to light:
1. Critique the plan: We know that Comprehensive Emergency Manage-ment Plans, or CEMPS, must be comprehensive, flexible, and critiqued and improved over time. The plans must be known by your area regulatory agency.
2. Transportation: We have learned that disaster plans have not adequately addressed transportation arrangements. Transportation contracts may not hold up in time of need. Many facilities discovered that there were multiple contracts with the same transportation provider.
3. Importance of utilities: Utility restoration has not been a priority in LTC facilities and that fuel supplies can be inadequate. In some areas, LTC facilities watched Wal-Mart get electrical priority before they did.
4. Generators and fuel: Additional challenges focused on generators and fuel needs. Common issues were generators that ran out of fuel or were only capable of providing short-term power for essential equipment. Some facilities went without power for two weeks. We learned the importance of educating the public about or scope of care and our need to be prioritized in a disaster.
5. National recognition: We have discovered that national recognition needs to embrace the needs of the vulnerable populations that live in LTC facilities. Recognition must take place at a state and national level, and facilities must look closely at how they manage acuities in normal and abnormal conditions.
6. Keys of communication: Commun-ication systems need to address internal and external links to the community, our resident population, our staff, and the stakeholders involved in LTC management.

Creating a Comprehensive Emergency Management Plan (CEMP)
       The disaster plan itself is the responsibility of the facility administrator who retains responsibility and authority to prepare, manage, and respond to actual and potential disasters. Having said that, the disaster plan will fail if it is not interdisciplinary and inter-related. Remember, it is called a “nursing home” for a reason. Areas that must be addressed within the plan include the chain of command, staffing, sleeping provisions, supplies, power, transportation, the facility operational plan, and physical plant readiness. Each state should check to be certain they are following state plan requirements.

Hazard Analysis
       The plan must be specific to different types of situations. As part of hazard analysis, a facility must be able to react to where they are the most vulnerable. That requires understanding of the facility location, structure, fuel and power resources as well as transportation arteries and providers, supplies, staffing, and acuity levels of the resident population. We discovered that transportation agreements may not hold up, and innovation is a necessity. Some providers received support from local churches that offered up vans, and are pursuing the possibility of using retrofitted motor carriers that can accommodate the needs of the elderly. Fuel shortages curtailed staff ability to come to work post disaster, and power outages kept gas stations from pumping. One of the biggest lessons learned was that you have to be prepared to live on an island for seven days. Roads are often closed, fuel is limited, and emergency rescue teams may be several days away.
       Staying in place is the best choice if storm surge and flooding is not a concern. Summit participants discussed “what would it take to harden a building as a means to stay in place”. The rule of thumb in a hurricane in a non-mandatory evacuation is: Run from water and hide from the wind.” Facilities must stay in contact with their local EOC and remain current with information on what flood zone they are in, and flood capacity.
       Facilities need to ready themselves to do a full evacuation as well as a partial evacuation. Facility damage from a roofing failure post storm could result in the need to relocate residents within your facility. That might include moving residents from an Alzheimer’s unit to another area of the building. Hazard analysis includes having a plan for such a scenario. Where is your free space, where could such a move take place, who are electricity dependent?

Communication
       Communication components within a plan must look at both internal and external communication plans. As part of the facility external plan, there needs to be alternatives to downed phone lines and cell towers. Suggestions include:
       • Have designated radio frequencies and radio transmitters.
       • Obtain assistance and support from HAM operators.
       • Obtain an off-site 800 number setup for phone rollover to a safe area. This number can provide updates for resident families and staff. The 800 line could be used to convey information on evacuation locations, or work schedules.
       • Local electronics vendors can provide discounts on walkie-talkies.
       • Update staff and family contact numbers.
       • Administrators have suggested having pre-prepared public service announcements for radio and television stations.
       The internal communication plan should include how information will be shared between departments, the interdisciplinary team, between work groups, and between residents, families, staff, and physicians. That should include how will resident specific information be shared and updated? How are staff assignments distributed? What are individual roles in an emergency? How is the chain of command established within the nursing department, and for the facility as a whole?

DON Role
       The Director of Nursing’s (DON) role in a disaster is to establish clinical priorities and assure the plan is well communicated. It is essential that the DON identifies the facility scope of care and has a plan to manage the acuities of a diverse resident population. As a starting point, it is helpful for the facility to understand the demographics of their resident population. Resident information should be updated on a regular and ongoing basis. The DON role is aligned in several areas as follows:
a. Clinical management: This acknowledges resident acuities and knowledge of what conditions could worsen. The nursing team should plan for how care is managed under both normal and abnormal conditions. The plan should acknowledge those at risk and those with special needs. (Information follows).
b. Clinical response to emergent situations: The plan should address significant “what if’s” such as power or environmental failure and clinical response to emergent situations. Tools such as CMS forms 672 and 802 can help categorize needs. The CMS QM/QI is also a valuable tool for clinical management.
c. Current and updated resident information. This should be ready to take with you in a waterproof transport system. Include Advance Directives, DNRO, allergies, contact information and responsible party, current Dx, treatments, medications, and the most recent plan of care. Provide for backup of records if you have computerized systems.
d. General considerations: Resident identification systems are critical in disaster management. In advance, have enough ID bracelets on hand. Identify name, resident, and standard medical information as well as critical information such as Dialysis, use of a thickener product, allergies, elopement, DNR, etc. Consider having eyeglasses and dentures engraved, along with resident photos. Some facilities keep backup files and information on a website or in a different secured location.
e. A (recommended) 7-days of supplies and equipment. This includes ensuring there is an adequate 7-day supply and that you involve the pharmacy and the Medical Director to periodically assess med utilization and the content of your emergency medication kit. Take into consideration acute management of emerging conditions such as pain, anxiety, and/or infection. Refer back to your “scope of care” to address potential needs in an emergency.
f. Delegation of duties and responsibilities. Have an advance schedule with 24-hour oversight addressing staffing, staff support, schedule, and contact information. Include a staffing plan that addresses 24/7 needs for at least seven days. Provisions should include 24-hour staffing plan until the emergency is abated. Track staff hours for future cost reports, and designate the chain of command within the nursing department. Staff also needs identification badges to ensure they can travel in curfew or restricted access areas.
g. Staff needs and considerations: This includes information on what supplies a staff or family member (if allowed) shall have with them; additional information could include a policy on pets and sleeping provisions.
h. Collaborative relationships: Consider having a disaster-planning meeting with vendors and related members of your community on a regular basis. This could include pharmacy, hospice, dialysis centers, physicians, home health agencies, vendors, the Medical Director and physician base, and emergency operations contacts. It is also worthwhile to establish relationships with local power and utility officials and government officials so they can attach faces to the people that they and you mutually represent.
i. Evacuation triage: This includes a plan for transportation requirements and a timeline for evacuation. Where are the major arteries? Is there a provision for allowing healthcare facilities to have an early evacuation, and can there be police escort provisions? What is the level of assistance needed by the residents? What is the mobility and healthcare status of the people being transported? What are the staffing levels on the bus or transportation carrier? Are supplies and equipment accessible and available during transport times? What type of motor vehicles will be used? Are there adequate fuel supplies available for transport?

Planning For Scope of Services: Vulnerability Assessment Based on Population Characteristics
1. Resident Characteristics: The facility should review internal resident population characteristics and related programs such as dialysis management, pain management, and behavioral management: Alzheimer’s care and related dementias, respiratory management and areas of specialization that reflect the needs of the resident population. The facility will manage the scope of care through the following set initiatives, in conjunction with care specific steps as noted in care categories:
a. The facility will provide generator and battery operated backup to provide interim power in the event of a disaster.
b. The facility will provide local EOC and utility companies with current contact information and account numbers.
c. These residents will be assessed for early evacuation for fluctuating, precarious, or deteriorating conditions, or environmental circumstances that place them at risk.
d. Arm bands and resident specific information will be current and portable
e. A 7-day resident and facility specific inventory of supplies and equipment
f. Contracts and verifiable transportation arrangements; prioritized by acuity/threat levels.
g. Current contact information for responsible party/healthcare designee.
2. Dialysis Management: Residents with end stage renal disease are vulnerable to power outages, transportation delays, and closure of dialysis sites. This population requires acute management of their renal condition.
a. Identification of alternate sites and transportation venues.
b. Pharmacy will work with the facility to secure a 7-day supply of related medications and an expanded EDK kit that is adequate to address elevated potassium levels.
c. Dietary will coordinate a renal diet.
d. The Medical Director will assist in the development of alternative protocols for management of ESRD (Kaoexylate, etc.).
e. The facility will utilize external resources such as CMS Publication # 10150: Preparing for Emergencies: A guide for People on Dialysis” which is available at www.cms.hhs.gov/ MLNProducts/downloads/10150.pdf.
3. Respiratory Management: This includes, but is not limited to, residents with respiratory conditions such as COPD, chronic and acute CHF, pneumonia, respiratory infections, asthma, and related disease state and problem conditions. They are oxygen dependent, or require respiratory management via vents, suction machines, nebulizers, bi-pap machines, or related respiratory equipment that requires electricity. Power outages could influence the ability to sustain an open airway and/or effective airway clearance and breathing capacity. This population is also more vulnerable to the effects of smoke inhalation or impaired air quality that may occur secondary to a disaster.
a. The facility will sustain a 7-day inventory of suction catheters, cannulas, oxygen masks, and related equipment needed to treat conditions of the respiratory tract.
b. Transportation arrangements that includes safety provisions for oxygen canisters.
c. Which staff is current with CPR?
d. Who are the residents with DNRO orders? Are advance directives current? Are ID bracelets current?
e. Are contact lists current, (eg. responsible party information)?
4. Pain Management: This includes, but is not limited to musculoskeletal, orthopedic, and neurological conditions. Power outages could influence the ability to sustain IV pumps used for the management of pain, in addition to the provision of ultrasound, hot packs, electric stimulation, specialty bed utilization, and modalities provided through nursing or therapy.
a. Pharmacy will work with the facility to secure a 7-day supply of related medications and an expanded EDK kit that is adequate to address the titration of pain.
b. List those on RTC dosing and route of administration.
c. Those on Hospice or palliative care programs
d. Non-pharmacological approaches will be utilized as appropriate to individual needs. Battery backup for specialty beds, or overlay mattresses.
e. The facility will provide local EOC and utility companies with current contact information and account numbers.
5. Behavior Management: This population includes, but is not limited to those with Alzheimer’s and related dementias, with psychiatric or mood disorders, or pre-existing conditions such as COPD or cardiac conditions that could be accelerated related to stress and anxiety. Power outages could accelerate behavioral manifestations, or declines in mood state. Outages also increase the risk for elopement within secured units or for those that use Wander guard systems.
a. Exits will be monitored. Is there a list and pictures of the elopement risks?
b. What are the typical and atypical behaviors?
c. Permanent staff assignments as available for continuity.
d. Resident preferences/routines identified.
e. Pharmacy will work with the facility to secure a 7-day supply of related medications and an expanded EDK kit for use as indicated per individual assessment and physician recommendations.
f. Diversional activities will be coordinated with staff/volunteers.
g. Are care plans or informational kardexes current? How will you reduce the potential for agitation?
h. In the event that this population must be transported to another area: What safeguards are in place to account for them if you lose power or relocate?
6. Infection Control Management: This population includes those currently undergoing TX of infection or those that develop acutely emerging infections. Vulnerabilities include those with communicable diseases such as clostridium difficile, MRSA, and VRE as well as respiratory infection, conjunctivitis, and related conditions. Power outages can impact the water supply, waste disposal, and the ability to operate electrical equipment used in the management of infections such as intravenous therapy, respiratory equipment, wound pumps, sanitizing equipment, etc.
a. Interim Generator and battery backup provisions will be coordinated.
b. The facility will provide a 7-day supply of gowns, gloves, gels, masks, biohazardous supplies, and related infection control products and equipment.
c. List those with ports or IV sites.
d. List those on Antibiotic Therapy.
e. List those with communicable conditions that may need to be cohorted or isolated.
f. Identify provision for waste management and biohazardous disposal.
g. Pharmacy will work with the facility to secure a 7-day supply of related medications and an expanded EDK kit for use as indicated per individual assessment and physician recommendations.
7. Hospice and End of Life Care Management: This population includes but is not limited to residents with an end stage condition, six months or less life expectation, or on Hospice. Conditions vary and symptom management is dependent on the underlying conditions and co-morbidities. Loss of power could impact on the ability to provide respiratory support, pain management, nutritional support, and surface support.
a. The facility will provide a 7-day supply of supplies and equipment targeted to symptom management and comfort, in keeping with advance directives and resident wishes.
b. Pharmacy will work with the facility to secure a 7-day supply of related medications and an expanded EDK kit for use as indicated per individual assessment and physician recommendations.
c. Current face sheets and list of advanced directives/DNRO, and designated decision maker information and contact numbers.
8. Falls Management, Etc.: This population includes a wide selection of the diverse and complex resident population. Areas of vulnerability could be related to power loss, call light system failures, environmental and situational hazards, changes, and alterations in care systems and routines to include factors such as loss of adequate lighting, failure of call light systems, and relocation, or a new arrangement to living quarters. Additional risk factors may include chronic or acutely emerging factors such as: cardiac problems, muscle weakness and/or fatigue, transient ischemic attacks; seizures, stroke; Parkinson’s disease, delirium, psychiatric or cognitive conditions, joint immobility, depression, unsteady gait, history of fractures, failure to use ambulatory aids, orthostatic hypotension, incontinence of bowel or bladder, impaired vision and/or hearing, dehydration, lower extremity swelling or edema, missing limb, illness such as infection.
a. Provide consistency in routine and caregiver as possible.
b. Involve in diversional or volunteer activities.
c. Provide provisions for enhanced monitoring with call system failures secondary to power loss.
9. Nutritional Management: This is a need that addresses the entire resident population. Varied diseases and conditions can influence vulnerability and create a need for increased nutritional requirements. Conditions such as COPD increase caloric needs during times of stress. Among these are acute infections that could emerge secondary to a disaster such as gastrointestinal influenza and/or related diseases. Power failure could create vulnerability in populations that require: Enteral or potential feedings, IV therapy, dialysis and those with the potential for unstable blood sugars, (often triggered by stress). Acutely emerging conditions may warrant enhanced IV support with increased risk for dehydration and related conditions. Evacuation from the facility creates the risk of prolonged travel time and risks associated with transfer.
a. It is important that a list be maintained to identify residents on special diets, (diabetic, renal, NAS, etc.) those receiving enteral feedings (especially bolus), those on supplements, and those at risk for weight loss or dehydration. Identify all supplies associated with diabetic management.
b. Review the inventory of fluid thickener products and resident specific feeding approaches for dysphagia management, and ensure 7-day supplies.
c. Identify residents receiving intravenous/parenteral nutrition or hydration.
10.Wound Care Management/Prevention: All residents are considered to be a risk. There are a variety of diagnoses, treatments and conditions that can present complications. Power failure and the risks associated with possible evacuation create vulnerabilities related to sustaining electric specialty beds, and related electricity dependent modalities associated with wound management and prevention.
d. It is important to maintain a list of residents on specialty beds and to have overlay mattresses or alternate surfaces available in the event of power failure.
e. List of those receiving enteral therapy or who have addition power dependent treatment modalities.
f. Gel cushions or seating devices for transport.
       This article has touched on some of the critical areas for consideration within a comprehensive emergency management plans. State requirements, federal guidelines, and individual assessment based on hazard analysis and working knowledge of your resident population is critical. Together we must be vigilant to the needs of those we serve, and continue to work with our state and national partners to expedite an effective emergency response system for LTC facilities. We are the voices of the most vulnerable. Each member of the team has a key role in disaster planning, and reading this article is an important beginning step to ensure that you are well prepared.