Is your ED ready for a disaster?

ED nurses need to be proactive in preparing for disasters

Too often, disaster preparedness falls by the wayside in EDs, notes Erik Auf der Heide, MD, MPH, FACEP, assistant professor in the department of emergency medicine at Emory University School of Medicine in Atlanta. "As a consequence, some institutions only put forth a token level of support for disaster preparedness. The main concern is to pass Joint Commission inspection and hold the required number of drills."

The task of disaster planning often falls on the shoulders of the nursing staff, without adequate funding or support. "It may be assigned, almost as an afterthought, to be carried out in addition to other responsibilities,' says Auf der Heide. "Little reward or recognition goes with this responsibility, and it is not always accompanied by an adequate amount of time, training, assistance, or other necessary resources."

This is extremely dangerous, emphasizes Auf der Heide. "It is almost worse than no preparedness at all, because it creates the false impression that an effective program exists," he says. "It is little wonder that organizations that allow disaster preparedness efforts to occur in this context often `get what they pay for.'"

To ensure that your ED is prepared for a disaster, follow these steps:

Include interorganizational planning. "Hospitals do not exist in isolation, but many plan for disasters as if they do," says Auf der Heide. Nurses should coordinate disaster planning with other hospitals, ambulance, and EMS systems, local poison centers, law enforcement agencies, fire services, airports, harbor authorities, and local military installations, he recommends.

If a multidisciplinary regional disaster planning committee does not exist in your area, propose that one be established, advises Auf der Heide. "The costs of training and equipment, such as interagency radio networks, can be reduced by purchasing or financing it for a consortium rather than for each individual organization separately," he says.

Include adequate training. Many EDs have a well-written disaster plan but lack an associated training program, notes Auf der Heide. "Paper plans are important, but a functional and effective plan is that which resides in the minds of the potential participants," he stresses. "Having a disaster drill that is not preceded by a formal training program is like taking the final exam without having attended the course. Drills should be the culmination of a formal training program, not a substitute for it."

Coordinate where staff will report to. "Regularly update your staff call-in list, and know which staff members are closest to the ED," says Susan Dunmire, MD, FACEP, assistant professor of emergency medicine at the University of Pittsburgh School of Medicine. "It's important that the staff know how to access the hospital during the disaster, including where to park and how to get into the hospital. They need to know where to report ahead of time so they don't just get there and flounder."

At the University of Pittsburgh, ED staff are told to report to a centralized location instead of their own department. "We've created a central reporting area that's approximately five miles from the hospital where everyone knows to gather and park," Dunmire explains. "Then staff are shuttled to the hospital so we don't have multiple cars arriving in an area which is already congested."

Make your plan user-friendly. "Remember, when the plan needs to be used in a real situation, the people who wrote it will probably not be there," says Robert Knies, Jr., RN, MSN, CEN, clinical nurse specialist for emergency services at Methodist Hospital Health System Minnesota in St. Louis Park. The ED's disaster policy outlines the responsibilities of the major roles in a checklist format to use as a guidance device (see ED's policy and checklist for ED charge nurse on page 131).

During a drill at Veteran's Memorial Medical Center in Meriden, CT, it was determined that on-call administrators frequently did not have a clear understanding of their role in a disaster, says Jessie Moore, RN, MSN, CEN, clinical nurse specialist in the ED. "An administrative checklist was developed to assist them," she notes.

Set aside area for family members who come to the ED. "We direct them to the auditorium at the other end of hospital so they are out of the way. We also have a paging system so we can keep them updated," says Knies. "Security keeps access points to the ED secure. In a pinch, even a maintenance [staff member] can man a door. It's difficult if you do a lockdown of the department, because it also locks down the ambulance doors and hinders access."

At Methodist Hospital, ancillary staff such as orderlies or nursing assistants are used as runners to circulate the name, age, and condition of patients to the family area in the auditorium. "It's the safest way, because you can't rely on radios or internal communication, and anybody can carry messages," says Knies.

The ED's patient representatives keep the board in disaster control updated and communicate to disaster control. "Eventually, the system will be computerized, but you can't rely on that either if you have an internal disaster and the power goes out," notes Knies.

Consider internal communication. At Methodist, an internal hot line with a recorded message can handle 50 calls simultaneously. "That way, the rest of the facility can find out what is occurring during the incident," says Knies. "The message is initiated at the onset of the disaster and updated periodically."

Know your community's potential for disaster. "There may be factories operating in your community which are dealing with dangerous chemicals," says Dunmire. "Consider mass transit, trains, airport, obviously any radiation facilities, and any large day care centers."

Activate components of the plan as needed. "It's not an all or none response. Different parts of the plan are activated depending on our needs," says Dunmire. "Each facility would have a different definition of what a disaster would be."

What a disaster is for one ED may not be for another facility. "If you're a 24-bed hospital and there is a bus accident, you may need to activate the whole plan, but a 600-bed hospital would not," says Knies. "With our plan, we can activate specific parts as the need arises."

It may be sufficient to activate minor components of the plan. "Sometimes, you may just need to activate housekeeping if victims drag a lot of dirt into the ED and it needs to be cleaned up. Or, if there are a lot of victims with minor injuries, you may need dietary," says Knies. "Instead of bringing a large number of extra people in, you should be able to activate certain parts."

Handle calls from family. A commonly overlooked problem is the glut of incoming calls from worried family members. At Methodist, patient representatives and hospital chaplains field those calls. "The operators know not to direct the calls to the ED or disaster control," says Knies. "Once the station is activated in our main auditorium, that is where all the phone calls go."

Methodist Hospital now keeps a log of all calls from family members. "We learned this after a tornado struck the area," says Knies. "One hospital kept a log and ended up receiving/returning over 400 calls within 24 hours."

Minimize losses from disasters. Many hospitals have neglected this area, says Auf der Heide. "Often appropriate mitigation measures can prevent expensive losses, but, more importantly, they can assure that medical facilities can still take care of patients when they are most needed," he stresses.

Precautions should be taken depending on where your ED is located. "Hospitals located in the flood plain lose backup power because generators are located in the basement, which is an early victim to water damage," he notes. "Medical facilities located in high-risk seismic areas have not taken the most basic and inexpensive measures to anchor critical medical equipment so it doesn't fall off the counter and break. Hospitals in tornado- or hurricane-vulnerable areas have taken no measures to protect windows from breaking."

Consider backup systems in advance. Critical equipment, such as CT scanners and two-way radios, are often connected to circuits not included in backup power arrangements. "Critical medical facilities have neglected to arrange with local phone companies to get essential service giving the institution priority when phone circuits are overloaded with calls," he notes. "Critical computer data, such as patient records or accounts receivable, are not regularly backed up off site."

Get buy-in from hospital administration. Disasters are high-consequence but low-probability events, notes Auf der Heide. "Often, disaster preparedness has to compete with many other, seemingly more urgent, daily priorities," he says. "Some hospital administrators might argue that economic survival in these times of shrinking budgets, diminishing Medicaid and Medicare reimbursements, capitation, and escalating health care costs, is the "disaster" that most urgently demands their attention."

Hospital administrators must provide a solid commitment for effective disaster preparedness, Auf der Heide stresses. "If these persons do not understand the organization's role in a disaster and the role of other organizations with which it must interact, then a coordinated disaster response may be doomed at the outset," he says.

Address decontamination. Although you can't prepare for every chemical, research is helpful. "If you have a factory dealing with any type of cyanide product, you need to have enough kits on hand to use with cyanide poisoning," says Dunmire. "On the other hand, if railroad cars go through your community transiently, you obviously can't prepare for every possible chemical they might be carrying."

Mass hysteria is also a potential outcome of decontamination. When a railroad car derailed with a chemical spill, victims came to University of Pittsburgh's ED claiming they were exposed to chemicals. "There was some exposure, but there were also people who stated they were severely short of breath from areas of the city who could not have been exposed," says Dunmire. "So, we were not only dealing with true respiratory emergencies, but also mass hysteria."

Enlist community resources. Local resources should be included as part of the disaster plan to be activated as needed, says Dunmire. "Child care may be needed if the ED staff is working double or triple shifts," she explains. "If you are treating a mass of individuals, local restaurants may be willing to supply food. Social workers or employees from a nearby psychiatric hospital may volunteer their services."