By Melinda Young
Effective disaster planning requires improved annual preparedness training, better focus on patient transition, more emphasis on rehabilitation after discharge, strengthened teams, and transitions of care contingencies.
- Case managers should be part of the emergency planning and offer help.
- Disaster plans should maximize efficiency while planning for patients’ needs and resilience.
- Teamwork is important during a crisis and helps prepare case managers and health professionals for their roles and responsibilities.
Disaster planning must encompass a growing number of potential crises, including wildfires, flooding, and hurricanes — all of which have increased in recent years. Healthcare facilities also should prepare for events such as terrorist attacks, mass shootings, earthquakes, and pandemics.
Case managers are essential to any crisis management and disaster preparation, says Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM, senior director of care management nursing at Cleveland Clinic.
“Case managers need to be part of an overall emergency plan. They need to be used to the full extent of their ability,” Davis says. “Case managers need to step up and say, ‘Here is how we can help you if there is an emergency.’”
The following are suggestions for how case managers can improve the disaster planning process.
• Improve annual disaster preparedness training. When creating a disaster plan, designate alternative space for high-intensity patients in a pandemic or other mass casualty event.
One lesson learned during the pandemic is employees need a place they can go to calm down and practice stress-reducing techniques.
“There needs to be designated quiet rooms for staff to retreat to,” says Wyona Freysteinson, PhD, MN, professor of nursing at Nelda C. Stark College of Nursing at Texas Woman’s University. Disaster plans should indicate which projects will be suspended during a disaster. Documentation should be streamlined.
Training should include how staff can maintain transparent and frequent communication, and how leadership will stay in touch with employees during a disaster, Freysteinson says. From a leadership perspective, disaster planning should address mental health needs and stress levels of staff. Also include ways to initiate virtual meetings for clinician engagements as well as with patient families.
• Focus on patient flow and transitions. Include techniques for improving patient flow within and across the healthcare system to maximize efficiency, says Paul D. Biddinger, MD, FACEP, chief preparedness and continuity officer at Mass General Brigham and vice chair for emergency preparedness in the department of emergency medicine at Massachusetts General Hospital.
“It is extremely important that we continue to build on the lessons learned, recognizing how patients need to flow from inpatient to outpatient, and recognizing the connections between hospitals and acute nursing facilities,” Biddinger explains. “We’ve learned very quickly during the pandemic that acute care hospitals that are unable to discharge their patients quickly cannot take care of new patients because they aren’t flowing correctly.”
Any obstacle to efficient flow creates problems for everyone. “We need to recognize, from the moment a disaster happens, how to discharge from the hospital environment to a skilled nursing facility,” Biddinger says. “We have to plan for patients’ needs and resilience just as much as we do in the acute care environment.”
Throughout the pandemic, the healthcare enterprise has been developing new models of delivering care outside the hospital. These include mobile response programs, hospital-at-home programs, and community paramedicine, Biddinger says. These new models of care allow patients to be transitioned safely home, shortening their length of stay.
“All of these things are rapidly becoming part of the healthcare landscape because of the necessity of the disaster response,” Biddinger explains. “We know how we can restart these things very quickly in a no-notice event if we have to rapidly discharge patients in response to a mass casualty incident.”
Case managers can create an appropriate outflow for patients during these crisis periods.
“If they have preplanned for that outflow, then they have a whole array of options for safe discharge,” Biddinger says. “They are effectively making the healthcare system bigger, and they’re augmenting our capacities and capabilities in time to help the hospital admit patients from the ER and elsewhere.”
• Consider rehabilitation needs at the beginning of a crisis. Hospitalized victims of most disasters, including the COVID-19 pandemic, likely will need some type of rehabilitation care after their hospital stay.
“Historically, we have placed very little attention on the rehab outcome (i.e., what happens after you save a life),” says Michel D. Landry, BScPT, PhD, MBA, aid worker with the World Health Organization and professor in the department of orthopaedic surgery at Duke University.
In many disasters, there is little talk about what happens with the survivors. “If we are prepared to preserve life, we better be ready to provide some quality of life to the people we saved,” Landry says. “It is not morally appropriate to only consider the acute, immediate intervention; we need to think about the rehab context for people who’ve survived.”
Landry travels to crisis areas around the world, providing rehabilitation training and services to those regions. Among his recent trips were visits to Armenia, following an ethnic and territorial conflict, and to Lebanon, where people were injured after an ammonium nitrate explosion.
“We’ve had a whole lot of people who’ve survived these crises with very traumatic, rehabilitation-sensitive conditions,” Landry says. “With intervention at the right amplitude and time, you can significantly invert the curve to improve really challenging mental health and physical mobility issues.”
• Strengthen teams. Research suggests health organizations should encourage and improve teamwork to help units perform effectively in emergency preparedness.1
“In general, we found that when there was more team-building activity and collaborative teamwork, there was more of a perception that people were ready for a crisis because they had a way of working through problems,” says Karen Donelan, ScD, EdM, Stuart Altman professor and chair of U.S. health policy at Brandeis University and senior scientist at Massachusetts General Hospital.
It also helps when members of the team believe their roles are clear. “They feel more prepared for disasters,” Donelan says.
Disaster teams can include members of different departments in a hospital or healthcare system. For example, case managers can be part of an emergency department disaster team, and primary care providers can be part of an acute care emergency response.
“In my hospital, we have internal medicine specialists on our medical crisis [team],” Biddinger says. “They come to the emergency department in a crisis because they know it will be crowded and they can help take over the care of existing patients in the emergency room, helping push the stretchers elsewhere to create room for new trauma victims.”
The same teamwork is true for case managers, who are an essential part of making sure there is capacity to treat disaster victims, Biddinger says.
Crisis response teams should be configured to include the needed skill sets within the teams. “Do you have people who understand that in that disaster this is what their role becomes?” Donelan asks.
The team’s planning and policies should reflect their healthcare organization’s environment, including state laws, local laws, and the local market for healthcare labor.
“Will we need to bring in people from other parts of the country? Do we need to do additional disaster preparedness training?” Donelan asks.
Although many major medical centers provide good disaster preparedness training, they were not ready for a different kind of disaster, like the pandemic.
“There are places that are probably really good at floods, earthquakes, fires, and shootings, and have that kind of trauma team. But this type of pandemic is a different type of crisis,” she says.
• Create care transition contingencies for a crisis. Case management departments can plan for alternative ways to transition patients during a major crisis or disaster.
In 2016, case managers at Cleveland Clinic thought of several contingencies in the event of riots or violence at the Republican National Committee Convention in Cleveland, Davis says.
“Every contingency that could be thought of was thought of. Thank God nothing happened,” she adds. “But the pandemic was different. It was a disaster no one was thinking about.”
Case managers are excellent at transferring patients, even under complex and challenging conditions, Davis says. During an emergency, case managers can call families or receiving hospitals.
“Those are skills they can do in their sleep,” Davis notes. “If you have the time, you can logistically plan transfers during a crisis. Case managers are very good at that.”
Case managers can find resources for patients and notify community healthcare providers to ensure patients are transferred safely.
“If you have social workers in your department, they can provide the moral support and counseling that is necessary in the middle of a crisis,” Davis says.
During some emergencies, it may be difficult to discharge patients to the usual community settings, including skilled nursing facilities, says Aram Dobalian, PhD, JD, MPH, professor and director in the division of health systems management and policy at the University of Memphis.
“The hospital may be trying to discharge patients to a nursing home, but the facility may not have places to put people. They may not be able to care for these patients during a disaster scenario,” Dobalian explains. “There tends to be a lack of planning along those kinds of needs and the needs of the medically vulnerable.”
Healthcare organizations should identify vulnerable patients. This is where case managers can play an important role.
“They need to identify people with functional or access limitations,” Dobalian says. “Because we really don’t know how the disaster is going to unfold, there needs to be thinking about this in the immediate response phase.”
- Donelan K, DesRoches CM, Guzikowski S, et al. Physician and nurse practitioner roles in emergency, trauma, critical, and intensive care. Nurs Outlook 2020;68:591-600.