For an entire generation, emergency preparedness was a way of life. During the Cold War, the Baby Boomer generation learned how to prepare for the threat of nuclear war. School drills, bomb shelters, and public address sirens were integrated into everyday life. As the Cold War ended, however, so did the vigilance for emergency preparedness techniques learned by that generation.
"All-Hazards" Emergency Preparedness
Following the events of September 11, 2001, and the subsequent threat of bioterrorism, an emergency preparedness against an "all-hazards" event emerged. Preparations to respond to bioterrorism, acts of terrorism, and natural disasters were incorporated into emergency preparedness principles to create an "all-hazards" defense.
What this "all-hazards" approach to emergency preparedness has not addressed is citizen complacency. A survey conducted by the American Red Cross and Wirthlin Worldwide found that "only 1 in 10 American households has a family emergency plan, a disaster kit and training in first aid and CPR" (Chin, 2004, p. 15). These principles are the basis for emergency preparedness and may be the difference between dying and surviving an emergency, yet only a fraction of the country is prepared to face any type of disaster. With the recent events related to Hurricane Katrina, it is clear that emergency preparedness has risen to new priority in the United States.
Emergency preparedness may be the difference between dying and surviving an emergency, yet only a fraction of the country is prepared to face any type of disaster.
Nationally, progress in emergency preparedness for an all-hazards emergency response continues. Since 2001, with the direction of the Department of Homeland Security, the Federal Emergency Management Agency (FEMA) channeled its effort in an all-hazards approach to disasters. Its mission contains four principles: "to lead Americans to prepare for, prevent, respond to and recover from disasters" (FEMA, 2004).
For the home care nurse, two of FEMA's four basic emergency preparedness principles--preparation and prevention-apply when addressing the patient's home care needs. Prevention, in this case, also includes preventing the loss of life. The necessary steps that home care nurses can take to ensure that they and their patients are ready for these emergencies are discussed below.
Prepare: Learn Possible Events and Response Plans
Home care nurses need to know about what types of events or disasters are more likely to occur in their particular area. This information is available through the nurse's county agency. After the nurse learns this information, families, extended families, and neighbors need to be informed of the patient's needs in the event of an emergency. Everyone should be aware of the home's evacuation plan and the community evacuation plan, as well as what role each person plays in both plans, should an emergency arise.
Assess Threat Risk
Home care nurses need to identify which threat or disaster poses the greatest risk to their patients. Table 1 provides a tool that can be used to assess a natural, human, or technological event in three areas: the probability it will occur, the risk to the patient, and the level of preparedness. Using this type of tool will help the home care nurse ascertain the specific threats to which patients are most vulnerable. Hospitals use a similar hazardous vulnerability analysis tool every year to determine threats and potential impacts on their facilities.
This is how the tool works. The home care nurse ranks each category according to the specific patient's probability, risk, and level of preparedness. The columns are then multiplied for a final score. The higher the score, the more that patient is at risk for that event.
For example, if a patient lives in Florida, the probability the patient will experience a hurricane is "high" (3), the risk to human life could be a "life threat" if the patient is unable to leave the house (5). The preparedness to that threat may be "fair" (2) because the patient may have experienced hurricanes and be prepared to deal with them. This patient has total score of 30 (3 x 5 x 2 = 30). A score of 30 would place the patient at moderate to high risk.
This analysis tool also helps identify exactly what constitutes a disaster for patients. For the patient who is ventilator-dependent, an electrical failure would be a significant threat to safety and well-being. The analysis tool also can assess, for example, the risk for a homebound patient in the event of bioterrorism, such as community smallpox exposure. The tool allows the nurse to assess the threat to the individual, as well as the individual's level of preparedness for such an event. This tool can be used for an entire caseload for a nurse and entered into a database, which can in turn be provided to the nurse and agency administration to be used in the event of a disaster. Assuming that electrical supply may be limited when the list would be accessed, it would be best to have it printed or accessible by use of a fully charged lap-top computer.
Learn Community Warning Systems
Community alert systems that are part of the larger Emergency Alert System (EAS), under the jurisdiction of the Federal Communications Commission (FCC), are designed to allow the President to communicate with the American people should a national emergency occur (FCC, 2005). Since 1998, EAS has been used by the National Weather Service to alert communities of weather dangers. The familiar phrase, "This is a test of the Emergency Alert System. This is only a test[horizontal ellipsis]" is used to test the EAS (FCC). Some small, rural communities use a Community Emergency Notification System, usually air-raid sirens or horns, to alert citizens of potential dangers. The home care nurse should be familiar with these systems and educate patients about what action should be taken when an emergency notification occurs.
A new type of alert in many areas is the "reverse 911" system (Table 2). This automated telephone notification system calls home phones to alert people to an emergency in their area. This is a relatively new system and may not be available in all areas of the country, or it may be named something different. In addition, the system may not be available during all types of disasters. Advantages of this system include the ability to quickly reach a large number of people in a short amount of time. If the person is unable to answer the phone or is not home, the system will leave messages on answering machines. These messages alert residents to what is happening and what the resident should do.
This system does have some drawbacks. It is unable to reach cellular phone users in a specific service area because of the way cellular numbers are assigned. It also cannot alert people who do not answer their phones and have no answering machines or answering services.
The system has been used effectively in the Glendale, Arizona, area to alert residents about chlorine leaks and missing children. Phone messages are played first in English and then in Spanish. This system is able to make 2,000 calls a minute. Home care nurses should arrange for system alternatives if patients are hearing impaired or unable to reach a phone and answer it. Setting up a neighborhood support network for patients who fall into this category would be a priority for the home care nurse.
Assess Patient Environment and Resources
Patient Environment
Perform an environmental assessment of the patient's home, neighborhood, and community for potential barriers in case of an emergency. For example, if the hazard assessment shows an immobile patient who lives in an area at high risk for earthquakes, the nurse needs to assess the bed and surrounding walls. Are there items that could fall off and injure the patient? Are shelving units secured to the walls? Is there a possibility that large items could fall and block the exits? Are there barriers over windows that prevent people from getting in or the patient from getting out if necessary? Does the patient have access to all exits?
Assistance
How will assistance reach the patient, and how will the patient be evacuated? Keep a clearly marked evacuation plan visible by the bed or on a wall in the patient's room that includes an escape route from the patient's neighborhood and community. If the area is prone to floods, which way would the patient be evacuated to stay safely away from flooded streams or canals? Does the family have a designated meeting area? If the family is away, would the patient be able to evacuate him- or herself or would others need to be included?
Family and Social Networks
In the event of an emergency, how fast can family members reach the patient? The nurse should meet the neighbors. Are they willing to assist in the event of an emergency? Gather important phone numbers for the patient and keep them in a safe place that is easily accessible by family and friends. Keep an out-of-town contact to notify in the event of a regional emergency (when people nearby are not able to assist). The American Red Cross can help with contacting an out-of-town relative or friend.
The American Red Cross recommends gathering six items at home. During times of emergency, basic items such as water, food, medications, clothing, bedding, and first-aid supplies may not be readily available. Store a good supply of these items where they are easily accessible to the patient.
Community Partners
Identify potential community partners to help care for the patient if family and the home care nurse do not have access to the patient. Which neighbors and community members could offer vital skills in the event of an emergency? Are the neighbors trained in cardiopulmonary resuscitation? In the event of hurricanes or floods, who is able to help secure the patient's home if the home care nurse and family are unable to get there? Locate the immediate emergency resources in the patient's community, including fire and police stations.
Local county public health departments are invaluable resources before and during an emergency. In addition, the Red Cross has a wealth of resources for preparation and assists people in emergencies. More information about the Red Cross is available at http://www.redcross.org. Free patient education resources can be obtained by calling your local chapter and asking for the "Disaster Preparedness for Seniors by Seniors" resource packet.
Build a Personal Support Network
It is important to have a variety of resources available in the event of an emergency. The best way to accomplish this is to build a personal support network of family, friends, and neighbors. This network can include anyone the patient trusts and who can be trusted to check on the patient should an emergency arise. People in this network should know the patient's capabilities and needs and be available to offer help within minutes of an emergency.
Give these supportive people a complete written assessment of the patient's needs and include copies of emergency contact information, a medical information list, disability-related supplies and special equipment list, evacuation plans, and any relevant documents. Other supplemental documents should include advance directives, birth certificates, deeds, insurance cards, car titles, house titles, and any other items that would be considered nonreplaceable and needed by the patient after the emergency is over.
Consider giving these trusted network members the keys to the patient's car and home (with permission from the patient), so they have access if the patient must be evacuated. In addition, arrange specifically how the network will contact your patient, for example, a specific signal, because the telephones may not be working. Educate network members on the use of patient care equipment and practice moving essential equipment and supportive devices.
Another option is CERT (Community Emergency Response Training) teams. These groups of citizens, usually from a community or neighborhood, undergo training to assist in emergency situations in their community or neighborhood. They learn first aid, cardiopulmonary resuscitation, fire suppression, hazard control, and search and rescue. CERT groups operate in 50 states, three territories, and six foreign countries (Chin, 2004). More information is available on their Web site: http://www.citizencorps.gov/programs/cert.shtm.
Prepare and Stock Supplies
The American Red Cross recommends gathering six items at home (Table 3). During times of emergency, basic items such as water, food, medications, clothing, bedding, and first-aid supplies may not be readily available. Store a good supply of these items where they are easily accessible to the patient.
Water
Keep at least 1 gallon per person per day and keep a 3-day supply on hand. Store water in plastic containers and avoid using containers that will collapse or break. In the event of impending emergencies, fill bathtubs, sinks, and washing machines with water. Note that floods and earthquakes can contaminate water sources. Teach patients to use bottled water in these circumstances. Rotate bottled-water supplies and clearly mark bottles with "use by" dates with permanent marker.
Food
Keep at least a 3-day supply of canned, ready-to-eat meats, fruits, and vegetables. Rotate your supply routinely to ensure the food's freshness. Remember that cold conditions in the refrigerator deteriorate rapidly once power is lost. Use refrigerated food immediately to ensure freshness and discard any food in the refrigerator if power is lost for longer than 12 hours.
Medications
Prescription medication will be difficult if not impossible to access during emergencies. Include at least a 3-day supply of the patient's medications in the emergency preparedness kit (see Table 4 for more information). Consider keeping a back-up written prescription of every medication in the emergency preparedness kit. Rotate the medication monthly with newer medication to guarantee that the medication has not reached expiration. Place medications and the kit in an easily accessible place that is not subject to great temperature contrasts or dampness.
Supportive Supplies
Be especially cognizant of the patient's individual needs. If the patient requires oxygen support, ensure there is always a 3-day supply. If the patient needs frequent suctioning, provide suction catheters and be prepared for any loss of electricity. These patients will need access to a generator should loss of power occur. Consider all possibilities.
Make certain there are adequate supplies to ensure warmth and comfort. Bedding, towels, and clothing can be easily bagged and set aside. Pack supplies for all weather conditions, including wet, cold, and extreme heat. Consider packing waterproof items, such as umbrellas, rubber boots, or ponchos, if you are in a flood-prone area. Prepare layers of warm clothing, socks, hats, and gloves for cold weather. Do not forget sunscreen, bug spray, wide-brimmed hats, and long-sleeve shirts if there is a potential for prolonged exposure to the sun, such as after a hurricane. Remember also that reflection off snow can pose the same effects of prolonged sun exposure.
Resources
Before an emergency arises, patients and home care nurses should know their local resources. Some of these include the local fire, emergency medical services, and police departments.
Summary
Home care and other team members visiting in the community need to use these fundamental principles of preparation and prevention to plan care for their patients in emergency or disaster situations. Taking the steps discussed can guard against the loss of human life and minimize the impact on vulnerable patients. Home care nurses must educate and familiarize themselves with resources within their community and they need to assess their patient, patient's family, and the community's capabilities and limits before disaster strikes.
There will be many opportunities to test the lessons learned, whether during a natural disaster or an act of terrorism; it is not a matter of "if," but "when" the need will arise to use the basic principles discussed.
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