Crisis Standards of Care: Are You Familiar?

by: Denise M. Danna, RN, DNS, NEA, BC, CNE. FACHE

Due to such disasters as Hurricane Katrina, the tornado in Joplin, and various other
catastrophic events across the country and globe, the Department of Health and Human Services (HHS) requested that the Institute of Medicine (IOM) create a committee to develop standards of care during disasters. As citizens, we frequently experience how our health care system and the infrastructure of a community can be overwhelmed in such catastrophic disasters.

Several reports were generated from the IOM committee on Crisis Standards of Care (CSC). The first report in 2009, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations developed a definition of crisis standards of care “as a substantial change in usual health care operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g. pandemic influenza) or catastrophic (e.g. earthquake, hurricane) disaster. This change in the level of care delivered is justified by specific circumstances and is formally declared by a state government, in recognition that crisis operations will be in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations” (IOM, 2009). The second report entitled, Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response (IOM, 2012) developed CSC templates to assist and guide individuals and organizations in CSC planning and implementation (IOM, 2012). Some of the main reasons that CSC protocols are needed in catastrophic disasters are to ensure that critical resources are provided to those individuals who will benefit the most, conserve limited resources, and ensure that all individuals receive the same access to the best possible care.

Nurses play a vital part in participating in the development of CSC. I was asked to participate in an interdisciplinary task force charged with developing crisis standards of care protocol. My section was writing “Delivery of Care Guidelines for Essential Inpatient Nursing Care” (Louisiana Department of Health & Hospitals, 2011). In developing the essential inpatient nursing care guidelines, the ANA report, Adapting Standards of Care Under Extreme Conditions: Guidance for Professionals During Disasters, Pandemics, and Other Extreme Emergencies (2008) was referenced. This report identified critical standards for healthcare providers that should always be maintained during a disaster (e.g. worker and patient safety, maintaining airway and breathing, circulation, control blood loss, and infection control (ANA, p. 16). Standards of care that could be adapted under extreme conditions included such activities as routine care (e.g. vital signs for non-acute patients), extensive documentation of care, and elective procedures (ANA, p. 16).

It is recommended that each hospital develop its own recommendations for providing essential nursing care during a catastrophic disaster that mirrors the community’s in which they live (Murray, 2012). Nurses serve an important role in disasters. Nurses should familiarize themselves with CSC and work within their organizations and communities to develop and implement CSC. During times of disasters, scarce resources may occur and nurses need to know how standards of care may be adapted while still providing safe, ethical and quality nursing care (Murray, 2012).

References

ANA (2008). Adapting Standards of Care Under Extreme Conditions: Guidance for
Professionals During Disasters, Pandemics, and Other Extreme Emergencies. Retrieved
from: http://www.homecareprepare.com/files/AdaptingStandardsofCare.pdf

Institute of Medicine (2009). Report Brief. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Retrieved from:
https://www.phe.gov/coi/Documents/Guidance%20for%20Est%20CSC%20for%20Use%20in%20Disaster%20Situations%20A%20Letter%20Rpt.pdf

Institute of Medicine (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Retrieved from: http://www.nationalacademies.org/hmd/Reports/2012/Crisis-Standards-of-
Care-A-Systems-Framework-for-Catastrophic-Disaster-Response.aspx

Louisiana Department of Health & Hospitals. ESF-8 Health & Medical Section. State Hospital Crisis Standard of Care Guidelines in Disasters (Version 1.2 September 2011).Retrieved from:
https://www.phe.gov/coi/Documents/LA%20State%20Hospital%20CSC%20Guidelines%20in%20Disasters.pdf

Murray, J. (2012). Crisis Standards of Care: A framework for responding to catastrophic disasters. AJN, 112 (10), 61-63.

Are Mass Shootings A Disaster

by Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAAN

Mass Shooting Events (MSE) are a public health crisis in America. “We are on track in this country to have more mass shootings this year than in 2017 (Gunviolence.org, 2018). That is clearly unacceptable. Although, it’s not about the numbers, it’s about people, and people are not statistics. The numbers speak to the ever-increasing plague of gun violence on individuals, families, communities, and our country. Thirty-four mass shootings (Gunviolence.org) in the first month-and-a-half alone of 2018”. Lack of effective gun control measures, mental health resources in this country along with extreme political views, extreme religious views, racism, hate are a deadly combination. Of course, these are not the only factors in the epidemic we are facing. If we can get upstream in this epidemic, perhaps we will need less reactive measures or even be able to prevent mass shootings.

2017 Gun Violence Statistics 

  • 61,507 Active Shooter Incidents
  • 15,592 Deaths
  • 3,996   Children / Teens killed or injured
  • 19 days in the year without a mass shooting.

Mass shootings represent a clear disaster event for public servants, the health care system and the nursing profession among many others. “Schnur makes several recommendations as a nurse researcher in her article ‘Is there a cure for gun violence’ for the nursing profession ultimately assisting in the prevention of mass shooting. https://www.nursingcenter.com/ncblog/january-2016/is-there-a-cure-for-gun-violence

  1. Increase access to mental health programs for individuals, families, and students from elementary school through college:
  2. Include a gun safety assessment as part of routine health screenings for all patients:4
  3. Several states continue to propose legislation to ban practitioners from documenting gun ownership in the patient’s record.
  4. Develop and implement Evidence-based Hospital Violence Intervention Programs focusing on:
  5. Improve Community engagement/outreach and education programs with initiatives targeting:
  6. Gather more data, conduct research and educate families on how to best protect themselves and their families from gun injuries”

“We can’t solve a wicked problem with naïve eclecticism. An epidemic of this proportion will take all sectors, public, private, non-profit and governmental, working together to solve this crisis. We, as nurses, some 3.9 million strong in the U.S., can be a powerful voice. Those with greater expertise will propose possible solutions including universal background checks, raising age limits, making bump stocks illegal, restricting certain types of guns from the general population, mandatory waiting periods, database reporting and many more.” We have the knowledge and wisdom to work from local, state, and national levels, from grassroots advocacy to legislative action. Prevention and mitigation should be our first priority along with preparedness, readiness, response, and recovery.

I can continue to applaud the bravery of those advocating for change, especially our youth – as small passionate groups of people can make a change, that can grow into a tsunami of moral virtue to do what is right!

References

Edmonson, Cole (2018) TONE Newsletter. Retrieved from http://www.naylornetwork.com/tne-nwl/articles/index-v2.aspaid=495235&issueID=58241

Gun Violence Archive (2018). Retrieved from http://gunviolencearchive.org/

Kodjak, A. (2018).What if we treated gun violence like a public health crisis. Retrieved from https://www.npr.org/sections/health-shots/2017/11/15/564384012/what-if-we-treated-gun-violence-like-a-public-health-crisis

Schnur, M. (2016). Retrieved from https://www.nursingcenter.com/ncblog/january-2016/is-there-a-cure-for-gun-violence

Hurricane Season—Are You Ready?

by: Lavonne Adams, PhD, RN, CCRN

How ready are you for a hurricane? Even if you don’t live along the coast, you are not immune to hurricane effects, since remnants of major storms can produce widespread damage from heavy rain, flooding, and tornadoes. Such conditions pose risks to health and safety, so prior preparation is crucial. As I write this entry, we are well into hurricane season, which runs June 1st to November 30th for the Atlantic, and May 15th to November 30th for the Pacific. If you haven’t already done so, consult https://www.nhc.noaa.gov/prepare/ready.php for many helpful recommendations and links so you can prepare your family, home, and vehicle before a storm and learn how to act in the event of a storm.

Highlights include:

  • Know if you live in an evacuation area.
  • Become familiar with National Weather System watches and warnings
  • Have a weather radio
  • Establish a communication plan in case your family isn’t together when hazardous weather strikes
  • Develop an emergency plan that includes your pets and includes locations away from home
  • Keep an emergency kit—including food and water—on hand in the event power goes out or roads are impassable
  • Check on elderly or disabled family and neighbors
  • Get your home ready for a storm. Be aware of what to do in case of power outages. Make sure you consider:
    • Clearing the yard of anything that could blow around and damage your home
    • Covering windows and doors
    • How to turn off your power
    • Filling clean containers with drinking water; filling bathtub and sinks for washing
    • Emergency charging options for devices like cell phones
    • Alternatives if home medical equipment uses electricity
  • Ensure your vehicle is travel-ready and has a full tank of gas
  • Keep an emergency kit in your car
  • Consider whether you need to shelter in place or evacuate
  • Be ready to leave; if you need to evacuate, follow instructions by local officials
  • Be careful while evacuating; watch for:
    • Flying debris
    • Broken objects
    • Downed power lines
    • Flooded roads
    • Tornadoes
  • Wait until the area is declared safe before you return home

The American Red Cross also has a useful Checklist for hurricane preparedness.

Lavonne Adams is an Associate Professor at TCU Harris College of  Nursing and Health Sciences

Disaster Preparedness and the Difference Health Care Providers Can Make

by: Charleen C. McNeill, PhD, MSN, RN

The United States (US) approach to managing risks associated with disasters has historically relied on governmental intervention (FEMA, 2011).  However, population shifts, the growing number of people living with chronic conditions and/or disabilities, and the growing number of older citizens living independently have forced a change in the focus of disaster preparedness efforts. To improve the nation’s resilience, the US government has shifted more preparedness responsibilities on to individual citizens (FEMA, 2011).  Because of this shift, significant access and service gaps exist.

Despite the launching of the Citizen Preparedness Campaign in 2003, the levels of emergency preparedness in the US have not increased (Citizen Corps, 2009; Al-rousan, Rubenstein, & Wallace, 2014; McNeill et al., in press).  Disaster preparedness levels among individuals in our society are even more in the forefront after the 2017 hurricane season and the devastation left after Hurricanes Harvey, Irma, and Maria.  During the months of August and September of 2017, Hurricane Harvey and Irma caused the death of over 200 people; thousands were left without water, food, shelter, and medical care (Moravec, 2017; Phys.org, 2017; Texas Hospital Association, n.d.). On September 20, 2017, Hurricane Maria hit Puerto Rico leaving in its wake an official death count of 64 (Kishore et al., 2018).  However, an increase in subsequent fatalities as compared to historical patterns of death in Puerto Rico suggest the death toll may be greater than 70 times the official estimates (Kishore et al., 2018).  The devastation caused by Hurricane Maria is still acutely impacting its residents to this day.

We must consider our part in the disaster management cycle and the interventions we can undertake to improve patient outcomes during the direst of times.  To prepare members of our society for emergent events, improve access, and decrease service gaps, we must consider how we, as nurses and health care providers, can educate our clients and assist them in becoming more prepared.  Recent research highlights the strong, positive relationship between health-care provider education of patients with chronic conditions regarding emergency preparedness and that patient’s emergency preparedness level, indicating a pathway for effecting change in preparedness levels among such vulnerable populations (Al-rousan, Rubenstein, & Wallace, 2014; McNeill et al., in press).  According to these studies, patients with chronic conditions who received emergency preparedness education from their health care provider were three to four times more likely to be prepared for emergencies.  It is imperative that we arm ourselves with the knowledge to educate our patients on how they can be prepared, inclusive of their medical needs, to facilitate better health outcomes after disasters.  I urge each of us to do just that.  The 2018 hurricane season is upon us.  Let us all take action and routinely include disaster preparedness education for our patients and clients starting today.

References

Al-rousan, T., Rubenstein, L., & Wallace, R. (2014). Preparedness for natural disasters among older US adults: A nationwide survey. American Journal of Public Health. 104(3). doi: 10.2105/AJPH.2013.301559

Citizens Corps. (2009). Personal preparedness in America: findings from the 2009 Citizen Corps national survey. Retrieved from http://www.citizencorp.gove/ready/researchshtm.

Federal Emergency Management Agency (FEMA). (2011). A whole community approach to emergency management: Principles, themes, and pathways for action [FDOC 104-008-1].  Retrieved from http://www.fema.gov/library/viewRecord.do?id=4941

Kishore, N., Marques, D., Mahmud, A., Kiang, M., Rodriguez, I., Fuller, A., … Buckee, C. (2018). Mortality in Puerto Rico after hurricane Maria. New England Journal of Medicine. doi: 10.1056/NEJMsa1803972. Retrieved from https://www.nejm.org/doi/pdf/10.1056/NEJMsa1803972

McNeill, C., Killian, T., Moon, Z., Way, K., & Garrison, M.E. (in press). The Relationship Between Perceptions of Emergency Preparedness, Disaster Experience, Health-Care Provider Education, and Emergency Preparedness Levels. International Quarterly of Community Health Education. doi: 10.1177/0272684X18781792

Moravec, E. R. (2017) Texas officials: Hurricane Harvey death toll at 82, ‘mass casualties have absolutely not happened.’ Retrieved from https://www.washingtonpost.com/national/texas-officials-hurricane-harvey-death-toll-at-82-mass-casualties-have-absolutely-not-happened/2017/09/14/bff3ffea-9975-11e7-87fc-c3f7ee4035c9_story.html

Phys.org. (2017, September 27). Hurricane Irma death toll rises to 72 in Florida. Retrieved from https://phys.org/news/2017-09-hurricane-irma-death-toll-florida.html

Texas Hospital Association. (n.d.). Special report: Texas Hospital Association Hurricane Harvey analysis: Texas hospitals’ preparation strategies and priorities for future disaster response. Retrieved from https://www.spartnerships.com/wp-content/uploads/Harvey_Special_Report_FINAL_web.pdf

Charleen McNeill is an Assistant Professor at East Carolina University, College of Nursing

Preparing Your Community for Power Outages

As nurses interested in preparing your family, friends and communities for disasters, it is important to remind others of some key actions to take to prepare for the most likely events. As we move to the summer months, powerful storms are likely across the nation. There are some key teaching elements to share with others regarding power outages.

The following are all from Simmons (2013):

  • Have back-up lighting plus spare batteries available.
  • Check the expiration dates on the batteries and that batteries have not corroded inside the flashlights.
  • Lanterns and candles may be used, but be very cautious that burning candles are not knocked over by children and pets.
  • Satellite phones will work, but are costly; cell phone text messages may work.
  • Do not open the refrigerator unless absolutely necessary; piling frozen foods together gives the food a longer “life”.
  • Turn off or unplug as many appliances as possible to prevent damage from a power surge when power returns.
  • When power is restored, turn circuit breakers back on, one at a time.
  • Do not burn kerosene, briquettes or any gas appliances indoors.

Simmons, G. (2013). Common sense and disaster preparedness: A quick guide for staying safe before, during and after any disaster, pp. 118-119. Journal of Emergency Management and American Journal of Disaster Medicine.

Submitted by Joanne C. Langan, PhD, RN, CNE

Guiding Disaster Training Using the ICN Disaster Competencies

Nurses who volunteer to be disaster responders need education and training founded in disaster nurse competencies. The International Council of Nursing Framework of Disaster Nurse Competencies (FDNC; Dorsey, 2009), edited by the World Health Organization and the International Council of Nursing, should be considered as a guide in the education and practice of volunteer disaster nurses to ensure an effective delivery of healthcare during and after a disaster event. The FDNC allows the volunteer disaster nurse to learn basic disaster context. It is structured using four domains: mitigation/prevention competencies, preparedness competencies, response competencies; and recovery/rehabilitation competencies. These four domains are further divided into 10 sub-domains.

The FDNC were written in 2009 and have not been updated, something that is needed. The competencies were offered as an option for countries that do not have such competencies already in place and, for those countries that do have competencies, as a means of updating/validating their competencies, to guide research, and to provide a framework for training nursing students and nurses who volunteer in disasters.

To ensure that volunteer disaster nurses possess adequate knowledge, skills, and abilities to respond in a disaster, these nurses need education and training founded in disaster nurse competencies, possibly those of the FDNC. This will protect populations devastated by disasters and ensure those nurses who volunteer and respond to these disaster do so with the requisite skills and knowledge needed.

Deborah S. Adelman, PhD, RN, NE-BC
Professor, Graduate Nursing Programs, Purdue University Global

Laura Kay Wood, DNP(c), MSN, CMCN, RN
Professor, Graduate Nursing Programs, Purdue University Global

 

Suggested Resources

Assistant Secretary for Preparedness and Response. (2016). 2017-2022 health care preparedness and response capabilities. Retrieved from https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/2017-2022-healthcare-pr-capablities.pdf

Dorsey, D. M. (2009). ICN framework of disaster nursing competencies. Retrieved from http://www.wpro.who.int/hrh/documents/icn_framework.pdf?ua=1

EM-DAT: The International Disaster Database Centre for Research on the Epidemiology of Disasters-CRED. (2017). Home. Retrieved from http://www.emdat.be/

United Nations Office for Disaster Risk Reduction. (2016). 2015 disasters in numbers. Retrieved from www.unisdr.org/files/47804_2015disastertrendsinfographic.pdf

World Disaster Report. (2016). Resilience: Saving lives today, investing for tomorrow. Retrieved from www.ifrc.org/Global/Documents/Secretariat/201610/WDR%202016-FINAL_web.pdf

Future of Nursing: Campaign for Action promotes the field of Disaster Nursing

The Future of Nursing: Campaign for Action has posted two compelling articles and a must-see YouTube video featuring Tener Goodwin Veenema, Phd, RN FAAN, an expert on disaster nursing and co-founder of the Society for the Advancement of Disaster Nursing. Dr Veenema is also prominently mentioned in both articles.

The Future of Nursing: Campaign for Action is funded by American Association of Retired Persons (AARP) Foundation, AARP, and The Robert Wood Johnson Foundation (RWJ) to advance the field of nursing based on the recommendations contained in the Institute of Medicine Futue of Nursing Report.

The Campaign for Action articles include ‘Hurricane-Battered Hospital Offers Lessons in Disaster Preparedness’ which describes how a hospital in Beaumont, Texas prepared for and remained open during Hurricane Harvey as well as ‘The Next Disaster: Are You Ready?’ which includes tips for nursing personal preparedness, enhancing the nurse’s ability to respond to disasters.

Disaster Health and Sheltering Course for Nursing Students

The Disaster Health and Sheltering course is a two-part awareness level course designed to engage nursing students in health volunteerism during disaster operations. The course is hosted on the website of Disaster Resistant Communities Group (DRCG) in Tallahassee, Florida. Part I can be completed as an independent study or taught face-to-face in a classroom. It consists of an historical American Red Cross video and a narrated PowerPoint presentation accessed through http://www.DisasterHealthandSheltering.org. At the completion of the self-study version, students access a link to a 10-question post-test which they print out and present to their nursing faculty as evidence that they completed Part I.

In Part II, students interactively apply Part I knowledge by participating in a shelter-specific tabletop exercise complete with case studies. The customized tabletop exercise was created by Mr. Chris Floyd, Exercise Designer and CEO of DRCG, in coordination with an internal steering group of Red Cross nurses. The Part II classroom exercise is led by a nursing faculty who partners with Red Cross nurses from a local Chapter.

After completing the 4-hour course, (two at home, two in the classroom) students re-enter the website and complete a “hotwash” or course evaluation, then are directed to a link to print out the course completion certificate. Students are then eligible for the American Red Cross Student Nurse Pin and are encouraged to join their local chapter.

Since the inception of the course, almost 13,000 student nurses have been trained.

Course Authors

Dr. Janice Springer
Janice.springer@redcross.org

Dr. Cheryl Schmidt
Cheryl.k.schmidt@asu.edu

Submitted by: Cheryl K. Schmidt, PhD, RN, CNE, ANEF, FAAN & Janice Springer DNP RN PHN

Are You Ready for a Winter Weather Emergency?

 

How ready are you for a winter weather emergency? When I began to write this entry, winter had been colder than usual for much of the United States, and a massive winter storm was approaching the east coast. Such conditions pose significant danger to health and safety. I thought that it was a good time to review preparedness for cold weather emergencies.

Consult https://www.ready.gov/winter-weather for many helpful suggestions and links to prepare your family, home, and vehicle before a winter storm strikes. Highlights include:

  • Establish an emergency communication plan in case your family isn’t together when winter weather strikes
  • Keep an emergency kit—including food and water—on hand in the event power goes out or roads are impassable
  • Winterize your home
  • Be safe with heat sources and generators—prevent house fires and carbon monoxide poisoning
  • Have a fire extinguisher and know how to use it.
  • Know how to shut off water valves
  • Check on elderly or disabled family and neighbors
  • Take care of pets; bring them inside
  • Know what to do in case of power outages. Make sure you consider:
    • Alternate heating sources including extra blankets or sleeping bags
    • Emergency charging options for devices like cell phones
    • Alternatives if home medical equipment uses electricity
  • Winterize your vehicle
  • Keep an emergency kit in the car that includes cold weather-specific items
  • Dress warmly—it’s especially important to cover head, ears, extremities.
  • Walk carefully
  • Drive carefully
  • Avoid overexertion
  • Protect from and watch for symptoms of frostbite and hypothermia

Submitted by Lavonne Adams, PhD, RN, CCRN

Climate and Weather Related Disasters Set New Records in 2017

According to the National Oceanic and Atmospheric Administration (NOAA), 2017 was a historic year for climate and weather disasters, inflicting enormous costs in terms of human suffering and financial impact.  Costs have exceeded $300 billion, setting a new U.S. annual record.  Our hearts go out to the countless numbers of individuals who have been affected by the multiple hurricanes, fires, and other disasters which our country endured throughout 2017.  Less than two weeks into 2018, our thoughts are with the victims of the ‘Bomb Cyclone’ winter storm that slammed the East Coast as well as the victims of the California mud slides.  We cannot adequately express our gratitude to first responders and everyone who participates in emergency response and the aftermath; they are our true heroes.

In the early days of 2018, we recommit ourselves to advancing disaster nursing in the United States. Now, more than ever, ensuring “Every Nurse a Prepared Nurse” is a critically important goal.  Wishing you, and your families & friends a safe and healthy 2018.

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