Prepare staff, patients for the big chill with a cold-weather contingency plan

Here’s advice for dealing with winter’s harsh conditions

Two or three inches of snow brings some cities to a halt. Buses don’t run. Roads are closed. People can’t get to work. Two years ago, when the Seattle area was hit with over a foot of snow just after Christmas, the local media told stories about home care nurses skiing in to see patients on their own initiative.

Most agencies based in areas with traditionally mild winters don’t have contingency plans for cold-weather emergencies. That can place both staff and patients in danger. What can you do? Learn from the pros: agencies that deal with harsh winter conditions every year.

Each autumn, Western Illinois Home Health Care in Monmouth reviews its winter plan and re-emphasizes winter-safety precautions to staff and patients, says Anita Rutzen, RN, BSN, director of performance improvement/staff development.

The agency created its plan three years ago when it was first accredited by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Health Care Organizations (JCAHO). "It started out as a part of our general emergency preparedness plan," she says. "But while doing that, we realized we needed something more specific." Without a winter contingency plan, says Rutzen, there was a danger that no one in the agency would know how to make a decision on whether to declare a winter emergency.

Objective criteria make emergency decisions easier

She created a task force that included herself, two nurses, two home health aides, and a clinical supervisor. The task force developed a plan that puts the management nurse on call in charge of making a decision on whether to call a winter emergency. Rather than allowing a gut reaction to guide the decision, the task force decided to use objective criteria. "Then no one can claim the day was called on a whim," says Rutzen.

Those criteria are based on whether the National Weather Service is classifying a storm as a blizzard, or just calling for heavy snow. They also take into consideration whether there is a winter storm advisory, watch, or warning issued. The nurse on call either phones the weather service or the nurse can check on the National Weather Service’s Web site (www.nnic.noaa.gov/NIC/nwsfo.html) for the status. Only when there is a winter storm warning for most of the agency’s 10-county service area is a snow day called.

The nurse in charge then calls local radio stations and asks them to make an announcement that the agency is operating under a winter weather warning. "It’s a message to staff, really, to let them know they should call in," she says, adding the announcement is carefully worded to prevent patients who might be listening from panicking because their nurses might not be coming.

A phone tree is then used to ensure that all staff members are contacted about the emergency. The manager in charge ascertains which staff are mobile and determines which patients must be seen and who will see them. Rutzen says that she has even had staff use snowmobiles to get to patients.

Classify patients

Meredith Goodrick, RN, BSN, quality manager at Munson Home Care in Traverse City, MI, doesn’t have a specific winter plan, but uses parts of her general emergency policy and staff safety training policies to get through the winter.

Upon intake, all patients are given a rating of either A, B, or C. The ratings indicate a patient’s medical priority. All "A" patients have daily visits based on medical necessity. Patients who live alone are automatically rated "A." Patients rated "B" have a caregiver, but that person may not yet be trained. "C" patients are those for whom you can safely skip a visit, says Goodrick. A "C" patient might include someone who is a homemaker client or someone with a competent caregiver.

When an emergency situation is called, the managers on call in each of the agency’s offices start a staff phone tree. Each of those managers has a list of the patients and their rating, as well as a list for each county that lists whom to call if a patient must be seen. In some instances, it is 911; in others, a private ambulance company or the sheriff’s office. "Sometimes, a plow will take you in, and we have lists of which counties have snowmobiles, too," says Goodrick.

Then, patients are called, starting with the "A" patients. Those who can be rescheduled are, and those who cannot are visited by the nurse who lives closest to the client.

Rutzen’s agency also gives patients a medical priority, and assigns a staff member to make it out to the patients who must be seen. She keeps a list of which nurses have four-wheel-drive vehicles and snowmobiles for that purpose.

The regular daily schedule at Western Illinois Home Health Care also helps ensure that those critical patients have been seen if a snow emergency occurs later in the day. "Our nurses try to see the most critical patients early in the morning," says Rutzen. "Once nine or 10 a.m. has passed, we have dealt with the new patient on insulin, or those who need help out of bed."

One nice thing about home health, adds Rutzen, is that clients are often very protective of staff. The day before a predicted storm, she often gets calls from patients saying they want to reschedule a visit in order to keep a nurse off the road in a potentially dangerous situation.

Both agencies address winter preparation issues for patients during intake assessments. Munson nurses encourage patients to keep a week’s supply of food, medication, water, and heating fuel on hand. For those who may not be able to afford large quantities of fuel, Goodrick says nurses help clients by putting them in touch with fuel assistance programs. If a patient doesn’t qualify for a state-funded program, there are church groups and other private resources that can help.

Goodrick says one problem common in her region is old houses dependent on wood heating. For those patients, intake safety assessments also include a look at whether there are adequate smoke alarms in the house.

Staff motto: Be prepared

Rutzen says educating your staff on winter issues is at least as important as educating your patients. Every autumn, Western Illinois Home Health Care holds an inservice to remind staff of what they need to carry for their winter protection. The items they say are a must include:

• a small shovel;

• kitty litter, sand, or other abrasive items;

• newspaper, roofing shingles, or a small bit of carpet for traction;

• extra clothing;

• an ice scraper;

• snow chains that fit your car and which you know how to put on;

• jumper cables.

The agency also suggests that employees carry a "coffee can survival kit," an idea borrowed from the Illinois State Police. The kit includes items that can help someone trapped in their car in the snow or cold to survive until help arrives. (See survival kit list, above.)

Munson Home Care employees are told to carry similar items in their cars during the winter and add a few extra items such as a flashlight and batteries. They also are randomly checked to see that they do, indeed, carry those goods. "We don’t really have a problem, though, because most people take winter seriously," says Goodrick. "The problems occur when someone moves up here from say, Detroit, where they have maybe 40 inches of snow a year and figure they can handle what we get. But 40 inches isn’t 200," she says, adding that 200 inches of snow per year isn’t as much a concern as ice and cold.

Rutzen agrees that extreme temperatures are more worrisome. When the wind chill factor hits 40 degrees, she constantly tracks the staff. She calls patients to see that the nurse or aide has arrived and that both employee and client are well.

After a winter weather emergency has forced the plan to be put into effect, Goodrick leads a debriefing to see if any changes need to be made. "The first time we used it was because of a blizzard, and the problem we had was that some nurses felt they had to visit all their A’ patients, even if there wasn’t a scheduled visit that day. That was mostly an education issue. We tweaked the phone tree, too."

After the first winter her plan was used, Rutzen also surveyed the staff to see whether they thought it worked well. They did, she says. The plan is now reviewed every autumn.

For those unfamiliar with snow, Rutzen says you should educate your staff on its potential hazards. "I think home care nurses are just notorious for going around without jackets. They go from house to car to house. But they need to know, even if they don’t bundle up, they should have the gear available to them to do so."

Goodrick’s advice is to be sure nurses know that if they feel unsafe on the road, they shouldn’t wait for a manager to call them and tell them it’s time to call it a day, but to take the initiative themselves. "We are sitting in an office, not out on the road. If they don’t feel conditions are safe, they need to take themselves off the road and call us. A nurse in the ditch is no help to anyone."

Indeed, despite Rutzen’s plan, at least one nurse does get stuck in a ditch every winter — yet another reason, she says, why everyone needs to be prepared.