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Not Fully Prepared

Betty Sparks, RN (left), chairperson for the emergency preparedness task force of the Massachusetts Nurses Association and an operating room nurse at Newton-Wellesley Hospital, Newton, Mass., encourages all nurses – regardless of specialty – to get involved with their local community emergency response teams to gain basic skills in disaster survival and rescue. Photo by Winslow Martin.

Nurses will sleep more soundly in a post-9/11 environment if they know their nursing peers are trained to respond to the next emergency

Are we ready for the next disaster? Despite the focus on emergency preparedness and disaster response after 9/11, a series of reports released in June by the Institute of Medicine, including Hospital-Based Emergency Care: At the Breaking Point, says the nation’s emergency medical system is overburdened, underfunded, and highly fragmented. The reports conclude the system remains ill-prepared to handle surges that could result from large-scale disasters such as terrorist attacks, weather events, or disease outbreaks.

"We are better prepared, but we still have a long way to go," says Margaret McMahon, RN, MS, CEN, past president of the Emergency Nurses Association (ENA) and editor of Disaster Management and Response, an ENA-published journal.

At the federal level, improved cash flow to fund chemical, biological, radiological, and explosive training initiatives contributes to better emergency preparedness. Stockpiles of antidotes, antivirals, and antibiotics have been growing since 9/11. Bills on Capitol Hill are in motion to update and better integrate emergency communications, backup processes, and public alert and detection systems for weapons of mass destruction. The Homeland Security Science and Technology Enhancement Act of 2006 (HR 4941) was recently introduced.

But progress in emergency preparedness is fraught with growing pains for local health care organizations that face challenges never imagined before disasters such as 9/11 and Hurricane Katrina. Health care organizations have come to realize they might have to cope not only with local disasters, but with the fallout from massive disasters in distant areas of the country. After Hurricane Katrina hit, for example, thousands of displaced people were sent to communities in New England and the Chicago area. Local agencies launched huge regional responses to house, feed, and care for their medical needs.

Health care organizations are under added pressure to meet federal and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements to increase their self-sufficiency period from three to seven days in the event of a disaster. They must be able to maximize surge, supply, and service capacities to shelter and care for acute patients, patients with chronic conditions that require medical care, and potentially large numbers of displaced healthy people who need basic health services.

All hands on deck

To better prepare facilities for disaster, JCAHO has toughened standards for health care facility emergency preparedness exercises and drills. The JCAHO standard regarding emergency management drills (EC.4.20, revised July 1, 2006) emphasizes a continuous quality improvement approach to planning, conducting, and evaluating emergency management drills. Exercises must address the limits of an entire organization and incorporate drills based on organizational weaknesses. Also required: community involvement in exercises, an appointed individual who is responsible for monitoring drill performance, and a multidisciplinary critique process.

But meeting new standards can be a heavy load to haul for health care systems that already are overburdened and underfunded. "If you don’t have space to put regular patients, where are you going to put disaster patients?" says McMahon. "There’s frequently no funding for additional staff to come into practice. Until hospitals have financial support, they are going to be limited on how well they can drill with the whole hospital."
"I know CPR – can I help?"

In a post-9/11 world, it has become clear that hospitals and hospital nurses cannot bear the entire burden of a large-scale disaster. Nurses working in all specialties and venues need to be prepared to help communities and health care facilities respond to disaster.

"Even if you are not working in a hospital, you are still an excellent resource to get your community stabilized in a disaster," says Betty Sparks, RN, chairperson for the emergency preparedness task force of the Massachusetts Nurses Association and an OR nurse at Newton-Wellesley Hospital, Newton, Mass. "You have to realize, however, that you cannot just show up unprepared on a disaster scene – you have to have training." Sparks also is a member of the Massachusetts 2 Disaster Medical Assistance Team, and the Norwood, Mass., Community Emergency Response Team (CERT).

Sparks encourages all nurses to get involved with their local CERTs. Developed and implemented by the Los Angeles City Fire Department in 1985, CERT training has expanded across the country as an avenue for nurses and other community members to learn basic skills in disaster survival and rescue. The goal is for citizens to be able to care for themselves and their neighborhoods until additional resources are brought into a disaster zone. Training includes light victim search and rescue, fire safety, team organization, and disaster medical operations such as first aid and triage processes.
"We have to be able to take care of ourselves – that’s what CERTs teach you," says Sparks.

In the aftermath

After a disaster’s search and rescue phase concludes, the need for nursing skills representing every background becomes crucial.

"Once the infrastructure of a hospital or a community is wiped out, people with managed chronic diseases such as kidney failure or diabetes can become acute," says Mary Connelly, RN, CEN, administrator of the Illinois Nurse Volunteer Emergency Needs Team (INVENT). "The primary need in the aftermath of disaster is nursing care. Everything nurses do can be adapted to disaster recovery response – it’s not just meant for ED or hospital nurses."
At the hospital level, the massive impact of 9/11 and Katrina brought emergency preparedness activities and drills out of the ED and into the entire facility. "We have stopped calling it emergency preparedness – we now refer to it as hospital preparedness," says Sharon Ward, RN, MS, director of emergency and surgical services at Advocate Illinois Masonic Medical Center in Chicago. "Everybody needs to be involved.

"Hurricane Katrina and 9/11 changed the paradigm of how we plan for emergency preparedness," Ward continues. "Since then, the city of Chicago has made major strides in partnering with community planning groups to better prepare."
A seat at the table

Connelly also believes nurses are vital to emergency preparedness planning and training. "A disaster is going to fall on the shoulders of nurses, yet we’re not yet at the planning table," she says. "So much training has come out of emergency medical services or administrative rules and regulations – very little of which involves the nursing process."

New England nurses are addressing the absence of nurses during the planning phase. The emergency preparedness task force of the Massachusetts Nurses Association (MNA), for example, is playing a key role in centralizing and consolidating emergency preparedness and disaster leadership training for nurses.

"There is a lot of training being done, but it’s happening in different silos, and there is no big plan and no one has the big picture," says Christine Pontus, RN, COHN-S, associate director for MNA. "We are giving our nurses an all-hazards approach so they can use basic skills in any event."

The MNA’s course, Disaster Preparedness: An All-Hazards Approach for Nurses, provides an overview of the all-hazards approach to emergency preparedness. This approach requires a plan that is adaptable for scenarios ranging from weather-related disasters to pandemics to terrorism incidents.

MNA also offers a variety of continuing education programs designed to better prepare nurses for expanded roles in emergency preparedness. Its programs address topics such as the effects of explosive devices, emergency medical response to hazardous materials and acts of terrorism, emerging infectious diseases, and incident command systems for health care providers.