R O B I N A . B L E I E R , R N ,A N D R O B J . B E C H T

WHILE THERE IS NO GUARAN-tee that a disaster will occur,preparation for such an event

is a necessary part of managing risk. Itis plausible that every facility adminis-trator and every facility, at some time,will be required to respond to a disas-ter. This is what happened inFlorida in 2004, when aseries of vicious hurricanesforced nearly every nursingfacility in the state torespond to disaster condi-tions. The devastating impactof Hurricanes Katrina andRita on the Gulf Coast in2005, and the tragic resultsthat followed, further substantiate the need for preplanned disaster management.

Getting Started Although it can be over-whelming to prepare forevery possible contingency,facility disaster managementcan be broken down intoseven distinct planning areas:

1.) Patient-resident population andtheir clinical care needs;

2.) Staffing estimations and preparations;

3.) Supply requirements (medicaland otherwise);

4.) Pharmaceuticals;5.) Medical records; 6.) Physical plant considerations; and7.) Operation logistics.Whether the facility is a veteran of

previous disasters or new to disasterplanning, reviewing these seven plan-

ning areas will assist in facility prepara-tions for impending disaster scenarios.

Meeting Patient NeedsIn the initial planning phase, facilitiesmust compile—and keep up to date—information about patients’ conditions

and needs. These needs must always be met, even during a disaster.Furthermore, disaster conditions orstress brought on by a disaster mayexacerbate many patient health conditions.

In a skilled nursing facility (SNF),Form 672 and 802 reports are sup-posed to reflect the patient case mixfor ready reference. In states likeFlorida—or any area subject to fre-quent hurricane strikes—such reportsshould be updated weekly during thehurricane season ( June 1 through Nov.

30). Needs may include dialysis; venti-lator dependency; receiving other out-side treatments; bed-bound patients;and patients in a secured unit, who ide-ally should be evacuated to anothersecured unit or kept under directobservation.

Knowing the needs of eachpatient will be especially crit-ical if a facility is workingwith outside services (localpolice or fire departments,for example) during a massevacuation. Facilities shouldhave emergency identifica-tion protocols in place fortransmitting such criticalinformation, as well as resi-dent identifier information.Such protocols should identi-fy patients in terms of who isresponsible for their medica-tions; any potential allergies;positive diabetes status;required use of thickenerproduct for dietary reasons;patient’s physician and familymember contact; and any

other critical diagnostic information,including risk of elopement.

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Forging A Plan For DisastersWhile major disasters are hardly an everyday occurrence, all facilities shouldhave detailed plans in place and be prepared for the worst.

ROBIN A. BLEIER, RN, LHRM-FAC-

DONA, chairman of the Florida HealthCare Association’s (FHCA) DisasterPreparedness Committee, is a principal ofRB Health Partners and of CareResources, both located in Palm Harbor,Fla. ROB F. BECHT, CNHA, CHE, alicensed nursing facility administrator, is ahealth care attorney with Snell & Wilmer,Phoenix, Ariz. The two helped developFHCA’s “Disaster Planning Guide.”

When facilities are prepared, they can effect positive outcomesfollowing disasters.

Develop A Staffing PlanBecause each disaster is unique andmay be unexpected, staffing plansshould be developed in advance tomeet a range of contingencies. Thisrequires participation of staff from alldepartments, especially nursing, duringthe planning process. Administratorsand department managers must knowbeforehand who can be counted onwhen a disaster strikes.

At the same time, providers mustrecognize that staff members havehomes, families, pets, and a host ofother personal disaster-response needsof their own. Recognition of theseneeds is likely to encourage staff par-ticipation in helping to meet the disas-ter needs of the facility and its patients.Providers should consider using stafffamily members as part of the disaster-response team.

When developing a disaster staffmodel, split disaster teams work best.Four staff teams should be planned totake action during different phases ofthe disaster: Team 1, before, during,and after; Team 2, before and during;Team 3, before and immediately after;and Team 4, during and immediatelyafter. Ideally, department managers,administrative nursing staff, and otherkey facility staff should be available forTeam 1 duty. It is the job of the facilityadministrator to consider staff needs,patient needs, and staffing require-ments before making facility rules anddeciding on team placement.

A perception of fairness is critical,since the No. 1 role of the administra-tor in developing a disaster staffingplan is to make sure staff “buy in” tothe plan.

Minimum necessary staffing levelsshould be determined, planned for, andrecorded in writing—electronic timeclocks may become inoperable—unlessotherwise waived by a state agency.Staff records will show compliance inthe event that a state agency performsfollow-up surveys after the disaster haspassed. The amount of staffing timeworked and compensated may also be

needed for post-disaster insurance andinterim cost reporting. One goal indisaster recovery is ensuring that thefacility is properly reimbursed for dis-aster-related expenses.

Plan To Be Self-Sufficient Every facility should plan to be self-sufficient for up to two weeks, becauseit may well take that long for the nextdelivery of supplies. Each departmentshould plan comprehensively accordingto this two-week schedule.

This means planning for the needsof specific patients, which can beextremely complex. For example, dia-betic patients will need glucose moni-toring units (plus batteries, tests strips,and lancets), various types of insulin,and syringes, a sharps container tosafely dispose of sharps, alcohol forcleansing the pre-injection or blood-sugar testing site, instant glucose(tablets) in case of hypoglycemia, andany oral medications that the patient istaking for the disease. Diabetic physi-cian orders and medication administra-tion records must be followed andproperly documented to ensure thaterrors do not occur.

This planning process must berepeated for all patients with special-ized needs. Each and every aspect ofneeded care must be planned to ensurean adequate two-week supply. To easethe burden and assist with disaster pro-visioning, a disaster order of necessarysupplies should be prewritten and pre-planned with vendors in a manner thatis easily updated based on currentpatient needs.

In situations where the facility willevacuate to a specified location, it maybe possible to arrange for delivery ofthe disaster supply order directly to thereceiving location, thus saving stafftime in packing and transporting.

Pharmacy, Medical Chart NeedsPharmacy is critical during disasteroperations and must be treated as aseparate function.

Assuming little to no assistance from

the institutional pharmacy vendor(some may be more helpful), providersshould develop a plan that includes: 1.)a breakdown of medications into rou-tine, PRN, narcotics (routine andPRN), and intravenous; 2.) a break-down within each of these categoriesinto oral, injectable, nasal, optic, otic,liquid, and medications that requirerefrigeration; 3.) a determination ofpharmaceutical inventory levels foreach category and subcategory, toensure availability of a minimum two-week supply of all medications; 4.) acomplete and detailed listing of allmedications and supplies that are req-uisitioned from the pharmacy vendor(enteral, syringes, and plastics, forexample); and 5.) designation of onelead nurse to complete the facility’sdisaster pharmacy order and anothernurse to double check the order.

Complete active medical recordsmust be available and maintained dur-ing a disaster or an evacuation—notjust certified nurse assistant flowsheets. Active records may be tapedclosed (use clear packing tape asopposed to duct tape because it can beeasily cut open or retaped as necessary)to prevent lost or misplaced records.

Other active patient medical recordsthat are maintained at the nurses’ sta-tion should be taken out of their spe-cial books or binders and placed in thepatients’ separate active medical charts.Facilities using electronic files shouldrefer to policies and procedures relat-ing to the specific electronic systemand plan accordingly.

Secure The Physical PlantAdministers should evaluate the facili-ty’s physical plant and determinepotential weaknesses and possibleadaptations that may be made.Frequently, buildings can be hardenedso that potential disasters will not haveas detrimental an effect on the buildingand its functionality. Hardening a facil-ity in such a way that allows the facilityto operate and serve patients throughdisaster conditions must be considered

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due to the likelihood that evacuationplans may fail or that limited time maybe available to evacuate patients.

Hardening projects may include hur-ricane shuttering of exterior openingssuch as windows, doors, and through-wall air conditioning (AC) units; rooftie-downs and roof sealing; central AC

protections; removal of possible pro-jectiles from patios, balconies, and allsurrounding areas; reinforcement ofbuilding structural supports; and thecreation of safe areas within the build-ing core.

In addition to hardening, the physi-cal plant should be evaluated and

adapted so that operations can bemaintained. For example, facilitiesmust frequently rely on generators tomaintain electricity during and after adisaster such as a hurricane. But manyfacility generators are not wired toinclude AC systems or laundry facili-ties. This is not sufficient. In hot,storm-prone areas like south Florida,generators must have sufficient powerto cool the patient living areas. Andthis is true for most parts of the coun-try in summer.

Additionally, no facility can operatevery long under sanitary conditionswithout clean laundry. Thus, theyshould have the capacity to conductlaundry operations with a generator inthe event that the facility must operatewithout utility power for more than afew days.

Because generator electricity is socritical to continued disaster opera-tions, the facility also should plan tohave additional fuel available and iden-tify methods to access fuel in the eventthat the facility is without electricityduring an extended recovery period.

Plan The LogisticsDisaster-operation logistics fall intothree main categories based onwhether the facility will evacuatepatients: operations through an evacu-ation, the evacuation plan, and opera-tions when sheltering in place.

First, the administrator should createan operational plan to maintain opera-tions before, during, and through anevacuation.

Patients’ needs must be continuallymet throughout all phases. This meansthat necessary equipment, supplies, andresources must be prepared, relocated,and made available to patients and staffthroughout the evacuation process.The administrator should plan andcoordinate the movement of allresources with facility managers andoutside parties (local fire department)and, as the final authority on disasterlogistics, be prepared to makeinformed decisions based on resource

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availability, patient needs, and disastervariables.

While the director of nursing will beresponsible for maintaining patientservices during the disaster andthrough the evacuation process, theadministrator is responsible for alloperational aspects and requirementsnecessary to support the maintenanceof patient services.

A plan should also be developed thatincludes defined roles for all managersand personnel. If the decision is madeto evacuate, staff should be prepared toperform their pre-designed roles with-in the necessary time frame, while alsomeeting all patient needs (timing ofmeals, proper hydration and toileting,and medication pass requirements, forexample). If possible, the evacuationshould also be accomplished at oppor-tune times that minimize potentialnegative effects on the patients. Forexample, completing the evacuation atnight reduces patient exposure todehydration and heat concerns.

Finally, given that evacuation maynot be plausible in certain cases, a dis-aster plan should include the ability tomaintain operations while sheltering inplace before, during, and after the dis-aster. Such a plan also may include themovement of patients to a predesignat-ed safe area during the height of disas-ter conditions. Or, the plan mayinclude rationing of resources andchanges in operations considering thatpost-disaster recovery may last longer

than a week. Sheltering-in-place plansmay also include provisions for staffand their families, which then createsthe need for additional resources suchas food and water.

Operation logistics are comprehen-sive, unique to each facility, and mustbe flexible enough to meet changing

disaster variables. Communications,resource acquisition and movement,and decision making are critical. Eachfacility’s disaster plan should includethe unique aspects of operations logis-tics necessary to continually meet itspatients’ needs through every phase ofthe disaster. ■

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■ Robin Bleier can be reached at (727) 786-3032 orrobinbleier@yahoo.com.

■ Rob Becht can be reached at (602)382-6506 or rbecht@swlaw.com.

■ The FHCA “Disaster PlanningGuide,” which includes sample proto-cols, is available through the AmericanHealth Care Association’s Web site atwww.ahca.org, click on “Bookstore,”and then click on “Disaster andEmergency Preparedness.”

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Reprint permission from Provider Magazine “Sept 2006”