Get involved with your hospital's disaster planning initiatives

Case managers can pay a critical role when there are mass casualties

As your hospital engages in disaster planning, make sure that your case management department is involved in the process, Beverly Cunningham, RN, MS, associate administrator, clinical performance improvement, Medical City Dallas Hospital, advises.

"Hospital safety officers and other administrators may not be aware of how important the role of case managers can be in the event of a disaster. Case management leaders need to step up to the plate and be as involved as they can in hospital disaster planning," Cunningham says.

People tend to think that handling the influx of patients who come into a hospital following a natural or man-made disaster is the responsibility of the emergency department staff but the role of case managers is integral to the success of a disaster plan, she points out.

When a disaster strikes, case managers are likely to have a major role in facilitating discharges so that the hospital is able to accept a surge of patients, adds Jeanne Eckes, RN, MBA, director of emergency preparedness for the North Broward Hospital District, with headquarters in Fort Lauderdale, FL. "In addition, they may need to facilitate transportation home for patients, set up home care for people who need it, provide them with durable goods and other supplies," she says.

In fact, the accreditation standards for emergency management planning from The Joint Commission point out that "managing the flow of patients through the organization is essential to the prevention and mitigation of patient crowding, a problem that can lead to lapses in patient safety and the quality of care."

In a mass casualty situation, the resources a hospital needs to manage the influx of patients are likely to exceed the resources and staff on hand, Cunningham says. "The hospital doesn't just need emergency room staff and bedside nurses. It needs people to help free up beds for the new patients and help with people who are in shock and grieving," she adds.

Case managers are well suited to be in charge of planning and facilitating the discharge of patients in the event that the hospital has to be evacuated or patients need to be discharged to make room for patients injured in a disaster, says Nathan Szenjniuk, a member of the Center for Healthcare Emergency Response, based in Nashville, TN. He recommends that case managers meet with the hospital's disaster planner and physicians periodically to discuss ways to facilitate patient flow in a disaster. He suggests scenario-based planning exercises in which the hospital staff discuss what would happen in the event of a particular disaster, such as a flood, a tornado, or an earthquake.

Case management directors should develop a department disaster plan and make sure that each employee is aware of his or her roles and responsibilities, Eckes advises.

In case of a disaster, case managers should expect to be called to triage patients or take on other duties. "The case managers need to be training in a number of different roles. They may be taken out of the case management role and placed in a different role if they are needed," she adds.

Case management directors need to think about where their staff are most likely to be needed in case of a disaster, Cunningham says. For instance, if the social workers typically are involved in discharge planning at your hospital, you need to designate who will counsel patients and family members after the disaster and who will be involved in discharging patients, she says.

"The biggest things that case managers need to know and understand in a disaster is how to do a quick look at patients and categorize who is available and who is not available for discharge," Cunningham adds.

Although Dallas was not directly affected by hurricanes Katrina and Rita, the hospital did go into minimal disaster mode to handle the influx of people being transferred from less safe areas. "When Hurricane Rita was headed toward our area and we thought we might have to empty the hospital, we sent through the hospital and gave every patient an assignment based on severity of illness," Cunningham says.

The case managers assigned every patient a priority number depending on their readiness for discharge. Patients who were a 1 could be discharged that day if needed. Those who were ranked 4 could not be discharged under any circumstances.

"We passed the information on to the nursing supervisor. If more patients had come in, they would have had some direction in identifying which patients might be discharged," she says.

Case management directors should make sure that their department's disaster plans are up to date and that each member of the staff knows what his or her responsibilities will be in the event of a disaster, Cunningham suggests.

Make sure that all telephone numbers and addresses for everyone on your staff are up to date, Eckes adds.

"The hospital needs to be able to get in touch with all employees in case of a disaster. If the case management director hasn't heard from an employee and can't get in touch, we need to have the correct address so we can do a welfare check," she adds.

Each department in every hospital at North Broward Hospital District has a communication tree that designates who calls whom in case of a disaster. The hospital system is exploring the possibility of an automatic dialing system to alert staff to come into the hospital, Eckes says.

Communication is integral

Communication is essential when a disaster strikes, Eckes says. "When case managers are getting ready to discharge patients, it's critical that they communicate the patient needs to the command center and get help in mustering up the resources that patient will need," she says.

After Hurricane Wilma struck the southeastern coast of Florida in October 2005, leaving some areas without power for as long as 20 days, the case managers delayed the discharge of patients who could not return to a safe location. They communicated the patients' addresses to the emergency operations center to make sure the power had been restored.

"We found out when the power would be restored and planned our discharge around that. If we knew that the power in a neighborhood would be back on in 12 hours, we knew we could safely discharge patients in that area," she says.

In addition to being prepared to pitch in and do whatever is necessary in a disaster, case managers should prepare themselves and their families for a disaster, creating their own personal preparation plan, Eckes advises. "I am a firm believer that everyone should have a preparedness plan, even for the most minor inconveniences like traffic tie-ups or road failures," she says.

Eckes encourages the hospital staff to have a family disaster plan and a family communication plan so that if they get stuck at the hospital the family will know what happened and they will know that their family is in a safe place.

Case managers should take the lead in talking with their patients about what they would do in the case of a disaster, Eckes says.

Make sure your patients understand evacuation plans and remind them to have a supply of medications and other necessities on hand, Eckes recommends.

"What may be a minor inconvenience for some people, like a power outage, can be critical for a number of individuals. That's why I always promote a personal preparedness plan and suggest that case managers encourage their patients to plan for disasters," she says.

The only way, though, to make sure your plan is working is to have practice drills and exercises, Eckes says. Her hospital system holds a variety of drills throughout the year. "We create an exercise plan with specific objectives; we may focus on one segment of the plan or the whole plan," she says.

During a full drill, the hospital system recruits several hundred students to act as victims and puts make-up on them to simulate injuries. The hospital system partners with fire rescue, law enforcement, emergency management, ambulance firms, and other organizations. As the victims come into the hospital, the treatment team treats them based on injuries they observe or tags attached to the "patients."

"When real incidents occur in the community, we critique our response to them as well and identify what lessons we learned and what changes we should make to our plan," she says.

Medical City Dallas Hospital had a disaster drill that simulated an avian flu epidemic when a family on a mission trip developed the disease and had exposed their fellow passengers on an airplane. "This scenario is different from a mass casualty. It has a slow onset and ebbs and flows over a period of months. We looked at how we would care for very sick people over a long period of time, how we could assure that we had the beds to handle other people exposed to the disease, and how we would counsel patients, their family members, and concerned people in the community," Cunningham says.

During its latest disaster drill in May, McLaren Regional Medical Center in Flint, MI, was alerted that it was about to receive 50 patients who were injured in an imaginary plane crash.

The case managers went to the units where the beds were most desperately needed and worked with the physicians to facilitate discharge.

After the drill, the staff sat down and discussed how the plan worked, says Diane Kallas, BSN, MBA, RN, director of case management.

"Knowing the staff, their areas of expertise, and what role each would be most useful in during an emergency is essential in the event of a disaster," she adds.

Here is some other advice on how case managers can be involved in disaster planning:

  • Communicate with your hospital's safely officer and anyone else involved in disaster planning and make sure that case management is a part of what is being planned, Cunningham says.
  • Make sure your department participates in hospital disaster drills, she adds.
  • Meet with your staff often to talk about what would happen in the event of a disaster and let them know what their role would be, Kallas says.
  • Come up with a game plan and run it by management so everyone will be in agreement, Kallas suggests.

"We all know what our individual roles are and what the department role is. We need to make sure it correlates with the organization's role," she adds.

Conduct a tabletop exercise just for your department with a disaster scenario and brainstorm on how it would be handled, Cunningham says. Gather up what you think your staff would need in the case of an emergency. For instance, the McLaren Regional case management department has created a disaster box with the disaster manual, sign-in sheets, and other materials that the staff may need in a disaster.

(For more information, contact Beverly Cunningham, RN, MS, Medical City Dallas Hospital; e-mail: Beverly.Cunningham@hcahealthcare.com; Jeanne Eckes, RN, MBA, director of emergency preparedness, North Broward Hospital District, Fort Lauderdale, FL; e-mail:jeckes@nbhd.org; Nathan Szenjniuk, Center for Healthcare Emergency Response, Nashville, TN; e-mail: nszenjniuk@gmail.com; Diane Kallas, BSN, MBA, RN, director of case management, McLaren Regional Medical Center, Flint, MI; e-mail: DianeK@mclaren.org.)