Include case managers in hospital’s disaster plan

Trained clinicians can provide vital help

Case managers can provide vital assistance during a disaster, Toni Cesta, PhD, RN, FAAN, knows from first hand experience.

When the August power failure hit Saint Vincent’s Hospital Manhattan (NY), where Cesta is the director of case management, the case management department spent 36 straight hours providing hands-on care for traumatized patients.

In the case of a disaster, Saint Vincent’s case managers are assigned to go to the cafeteria and care for the patients who have been discharged but can’t go home.

During the blackout, those patients included people who had been injured in the subway when the lights went out and people suffering from heat exhaustion and respiratory problems. Included in the mix were psychiatric patients, three newborns and their mothers, and patients who had been discharged from the hospital that day but couldn’t go home.

The social workers in Cesta’s department were called on to provide emotional support to the patients who had been through a traumatic event and to help others locate their family members.

"The bottom line is that experienced nurses and social workers can add a lot of value to a disaster plan," she says.

As soon as the power outage hit, the Saint Vincent’s disaster plan went into effect and the case management staff went to their assigned place in the hospital cafeteria and set up a discharge area for patients who had been released from the hospital or emergency department (ED) and had no transportation home.

During a disaster, New York City does not allow any emergency vehicles to transport patients out of hospitals. They are to remain free for casualties and only can transport patients to hospitals, she says.

Limousine services and other transportation companies couldn’t help because the power outage also made it impossible to pump gas into their vehicles. Family members couldn’t come and get the patients because the bridges and tunnels were closed and the traffic signals were out.

Within a short time, the Saint Vincent’s ED was jammed with patients. "It became clear that the [ED] was overloaded. They were seeing and releasing people and because the city wouldn’t allow us to transport them out, we had to put them somewhere," Cesta says.

Case managers put their ingenuity to work assembling what was needed to care for the patients. The patients with head wounds needed antibiotics; diabetics needed insulin; and people with respiratory problems needed inhalers.

"The patients we had there, technically, had been discharged, but many of them still were very sick. Some were sicker than they should have been, and we returned them back to the [ED]," Cesta says.

The hospital had a supply of cots that had been purchased for the staff to sleep on in emergencies, but they weren’t suitable for the patients because there was no way to keep them from falling off. The staff brought in hospital beds, but all of them had been raised for cleaning, and there was no electricity to lower them. The solution was to use the big chairs from the dialysis clinic. The staff brought oxygen tanks into the cafeteria for patients who needed oxygen.

Eventually, the Salvation Army brought in bottled water and food. Staff already had gone to the supermarket to buy sandwich materials. The news reports downplayed the severity of the power failure, Cesta says.

"They showed people camping out, laughing, and coping, but for our hospital and the patients, it was a disaster. The case managers essentially were up for 36 hours taking care of patients. It was dark and hot, and if you turned on the tap, you got brown water," Cesta recalled.

Don’t forget to plan for outpatients

Based on her experiences of 9/11 and during the blackout, Cesta recommends that hospitals come up with a means to care for outpatients during a disaster.

"Now we know we have to beef up the concept of the discharge lounge and equip it with medications and supplies as well as red plugs hooked up to our generator system," she says.

When creating a disaster plan, Cesta recommends looking for a clinically appropriate location in which to set up a discharge area. The area should be large enough to handle the influx of patients you might expect and should include hookups to the emergency generator system. She offers the following advice as well:

  • Don’t expect to be able to transfer people out of the hospital.
  • If your hospital uses electronic medical records, come up with a paper system for admissions and orders when there is no power.
  • Think through everything necessary to accommodate the patients’ needs. Establish a supply of medication, oxygen, and dressing changes — anything that patients might require for any period of time.
  • Develop a system to get medication orders from the ED and to get the medication the patients need from the pharmacy.
  • Line up sources for appropriate food and water.
  • Secure appropriate places for people to sleep or lie down.
  • Set up a system to accommodate patients who have been released from the hospital and ED who need continuing care.