Director Mel Brooks said it best:
“Hope for the best; expect the worst.”
That should be the motto for disaster planning.
SEPTEMBER 11, HURRICANE KATRINA, AND THE GREAT MIDWESTERN FLOOD OF 1993 are just a few examples of the disasters that have struck the United States in the last 15 years. Whether the disaster is man-made or the result of Mother Nature, it is necessary for healthcare facilities to prepare for the worst.
Blizzards, hurricanes, tornadoes, earthquakes, fires and floods can bring down a dialysis center in a matter of minutes. These catastrophes can cut off power, eliminate clean water supplies, and destroy roads that lead to medical facilities. Still-standing structures will be asked to handle the overflow from non-functioning hospitals and outpatient centers, and must have a plan in place for dealing with that overload.
A disaster plan must incorporate many disparate elements, all of which must be planned to the Nth degree. These elements include the following:
The National Kidney Foundation offers multiple resources and recommendations for patients and facilities. For patients, it lists the locations of dialysis clinics around the world, dialysis diets, and healthcare guidelines. For facilities, the NKF offers recommendations for posting signage or notices that the facility is out of water and cannot provide dialysis, and directing patients to an alternate provider location.
Assemble a disaster plan now if you don’t have one already. A disaster plan should include discussion and input from your local emergency planning department, your local health department, social services, emergency responders such as fire and police, and utility providers and transportation vendors, according to the Network of New England.1
The local ESRD Network should also have Internet capabilities in place, so that in case of emergency the Network can update its Web site with the status of open and closed dialysis providers. In addition, the Network will need to assist families in locating their relatives on dialysis, and also coordinate planning if a large area is affected by the disaster.1
According to a manual from the Centers for Medicare & Medicaid Services (CMS), when creating a disaster plan, “The three basic assessments you should perform are hazard site assessment, building and insurance review. Once these are completed, you can mitigate and prepare for the known hazards.”2
Remember, once the disaster plan is complete, it is essential to provide orientation and drills for all staff members, so they know what their roles are in an emergency. Establish a site plan that includes maps showing exits, utility shut-offs, gas lines, storm drains, fire extinguishers, floor plans, etc.2
Plan for insurance coverage for your facility—you will need to insure your technical infrastructure and electronic data recovery. If you are in a tornado-prone area, establish storm shelters. If you’re in a hurricane-prone area, establish evacuation procedures. Store records and sensitive technology or equipment at least two feet off the floor in case of flooding. Get portable pumps, sandbags and shovels. And there is another essential piece of equipment in any disaster plan: “Purchase a National Oceanic and Atmospheric Administration (NOAA) Weather Radio with a warning alarm tone and battery backup,” CMS recommended.
The Emergency Preparedness for Dialysis Facilities guide suggests, first, establishing a plan for emergency communications, as cell phones, land lines, and broadcasting services (television, radio) may be out of service. Communications, according to CMS, are often the weakest link in the emergency plan.
Plan for staff shortages and power outages. Have emergency generators on-hand if your risk of disaster is high.
Plan for portable patient records. CMS suggests a waterproof, portable box that can contain this information for each patient:
1. Medical Evidence Form (CMS 2728)
2. Hemodialysis orders
3. Admitting face sheet
4. Advance directives
5. Schematic of the flow pattern of the water treatment system
6. Census of patients and staff by shift
7. Phone numbers of both staff and patients
8. Mutual aid agreements
9. Service providers2
The NKF also focuses on communication, suggesting walkie-talkies for within the facility, and also the use of text-messaging services on mobile phones, instead of voice calls. “Lower bandwidth communication, such as text messages, may still be allowed to go through,” the foundation said.
In addition, form a relationship with the local ham radio club and four-wheel drive vehicle clubs. Both can be helpful for communication and transportation in a disaster situation.
Certain emergency supplies should be kept ready, including bandages, clamps and scissors at each dialysis station. Other items should include the following:
•Blood pressure cuffs
•Personal protective equipment
There are also special infection control considerations for specific patient groups, including those on peritoneal dialysis.
In addition to federal resources, most states also have advanced disaster plans and may offer supplies or support in an emergency. For example, the Missouri Department of Health and Senior Services offers a package of “Ready in 3” resources, which have been provided to dialysis facilities throughout the state. The centers are asked to share this material with all of the dialysis patients living in Missouri. The guide includes recommendations for medication and how to find dialysis centers that are currently in working order. Additionally, the resource includes a three-day emergency diet.
Lightning—and Flooding—Does Strike Twice
An article about disaster planning was authored by Sandra Copeland, RN, MSN, BC, a clinical nurse specialist and interim assistant director for dialysis at the Medical Center of Central Georgia in Macon. Copeland authored this article for Nephrology Nursing Journal in November 2005. Although the article was published immediately after Hurricane Katrina hit the South, Copeland had actually completed the article just before the hurricane. The recommendations she described in her article proved to be helpful during that natural disaster, but as she explained in an interview with Renal Business Today, “We had lived through the flood stuff already.”
In 1994, a flood in Georgia wiped out four water treatment plants in Macon, and for 30 days, the hospital had no municipal water service. Tankers that had formerly carried milk were instead recruited to cart water to the facility daily.
The dialysis unit learned through this experience that outpatient centers in the area did not have the resources to handle their own patients, so not only did the hospital have its own patients to serve, but also the additional load from the entire outpatient community. “We learned a lot from that,” Copeland recounted.
During later disasters, the hospital worked with dialysis facilities outside the area, asking those centers to add dialysis patients to their rosters temporarily. These experiences led Copeland and colleagues to establish close relationships with vendors who could provide supplies during emergencies. In addition, alterations were made to the dialysis services—such as shortening treatments. “Tankers drove in from Atlanta daily, and we calculated how many gallons of water we’d need to run two shifts, and enough water to do the disinfection,” she said.
After 9/11, with the establishment of the Department of Homeland Security, these arrangements shifted. The Georgia Emergency Management Agency (GEMA) is now the state authority for handling disasters. GEMA asks the facility how much water it needs, and the facility can no longer individually contract with water deliverers.
The medical center has had plenty of practice incorporating its evolving disaster plans. “We’ve tested the water thing in multiple ways,” Copeland recalled. “One of our sister hospitals had a tornado disaster. Two years ago, we had a category 2 hurricane through Georgia.” And the city of Savannah recently had to evacuate its hospitals, and those patients’ dialysis services were shifted to the Medical Center of Central Georgia. “We had to not only meet our patients’ needs, but also those of the people in Savannah,” she added.
Copeland has also learned much from other providers thrust into disaster mode; at one conference, she attended a session at which nurses caring for victims of the 1995 Oklahoma Federal Building bombing discussed the implementation of their own disaster plans. “They discussed how ridiculous the plan was according to reality. They said, ‘We’re going to use these conference rooms as triage areas,’ but learned that there weren’t wall outlets in those rooms because they were meeting rooms—they weren’t set up as a patient care area. The doorways were too short and narrow for X-ray equipment to fit through. They were supposed to function as hospital rooms for mass casualty stations, and were going to be used to get all the patients triaged.”
That, Copeland said, was a strong lesson. “It hit me—when you say you are going to do this, make sure the rooms are set up for power outages, that they have enough outlets, that they have the type of outlet that will allow a medical piece of equipment to be plugged in. Ensure that doorways are wide enough for stretchers and beds. Normally, they don’t have to meet those standards because they’re not a patient care area, but if you plan to convert them, you’d better try them out,” she advised.
Other concerns include:
•how to evacuate patients and bring their records with them, now that many records are electronic.
•how to evacuate everyone quickly in a situation such as fire or tornado that requires an immediate response.
Both national associations and large dialysis services providers offer emergency support, which is necessary, Copeland pointed out. “We may not be able to provide for everybody,” she said.
Copeland’s facility has learned a hard lesson in past emergencies—the hospital has had to pick up the slack of smaller facilities that could not, or would not, stay open. “Some physician offices could get water tankers in, like cardiologists’ offices, and those tankers would sit outside their offices to run their air conditioner. But some outpatient centers couldn’t get water. It would cost them too much. You can apply for FEMA grants that reimburse for things that wouldn’t be covered, but it can take years to get that money, and there is a ton of paperwork and red tape. Some outpatient facilities didn’t want that hassle, so they said it was too difficult, so the hospital can do it.”
The competitive nature of many dialysis facilities means that it’s difficult to get them all to work together in an emergency. “Theoretically, a task force of all the outpatient centers should be able to join forces and work together in those times, but that’s difficult because of the huge competitive nature of the market,” Copeland pointed out. “It depends on the area—we have competitors, but when we’ve come together on these evacuations of an entire community like Savannah with several large hospitals, they all pulled together. Our area has done well hospital-wise, but some areas may be more heavily managed care and more hostile.”
Another concern during disaster planning—one that is rarely addressed—is the disposal of hazardous chemicals. “That is something I would be curious about—our policy does not address that. I would like to see what people in New Orleans are doing, because they’re living it right now,” Copeland said.
But ultimately, water planning is one of the biggest issues and should be coordinated well in advance. The fire department, for example, typically has a number of “pumper” trucks, which can be used to provide water in an emergency. “That is in our plan as well,” Copeland said. “We coordinate with our GEMA person. If I called the fire department, and GEMA called the fire department, and they got 40 other water calls, in addition to dealing with fires, it would be very uncoordinated. So we have vendors and the fire department coordinated through our GEMA person. They ask us how much we need, which we calculate for 24 hours of water needs for a certain number of stations. It gives us a starting point. I had the company who maintains our R/O come up with a number based on each system, because each system uses water differently, depending on what percent they divert for water quality. There is different water flow for those that divert 70 percent versus those that divert 90 percent. Then you also have to take into account the water needs for providing dialysis for hepatitis patients and cleaning up after each treatment.”
Another important component during the emergency is water conservation—turning off all excess accessories such as ice machines, faucets and restrooms. In addition, the facility will need to stock up on its waterless hand sanitizer. “In 1994, there were no waterless hand sanitizers. We used baby wipes, and the infection rate was the lowest it been in our hospital in a hundred years. It may have been because we couldn’t wash our hands, so we were good about scrubbing with baby wipes,” Copeland related.
A final key to long-range water planning is arranging for a number of buckets for water transport. “We had a bucket brigade—you need buckets or some type of container available to haul water, because we’d have to pour buckets of water (not potable water) to flush the commodes with. We would do that after every tenth person went to the bathroom, because our water was rationed by EMA. We did this for a month—and that includes patient bathrooms. In addition, without water, you have no air conditioning in the summertime. That’s more long-term. Short-term, you’re not going to worry about that, but if you’re looking at long-term (more than a day or two), those are things you have to have available.” RBT
Offerings From Large Providers
EACH SUMMER, Fresenius Medical Care updates its annual Disaster Planning and Response Plan, based on the previous year’s experiences and expected conditions for the coming year. The program is designed to provide life-sustaining dialysis care for kidney failure patients in the event of a disaster, including the annual hurricane season, which runs from June through November.
Because patients typically need dialysis every two days, the company is prepared to accommodate any dialysis patient— including non-Fresenius Medical Care patients—who require treatment during a disaster. The plan involves coordination with federal and state agencies; national, regional and local emergency response teams; and scores of doctors, nurses and company employees. It includes the following key elements:
Patient Disaster Hotline: (800) 626-1297. The 24-hour hotline, staffed by experienced dialysis customer service specialists who deal with patients every day, will answer questions and direct patients and their families to the nearest open facility during an emergency.
Distribution of disaster preparedness information packets, which include patient-specific medical information.
Emergency power, back-up medical equipment and water tankers to help bring affected Fresenius Medical Care clinics back to operations quickly.
Pre-established procedures and clear lines of communications to coordinate national, regional and local teams.
Mobile homes and RVs to temporarily house employees during a disaster.
“Effective preparation saves lives. The goals of our plan are to make sure every patient has access to quality dialysis care and to restore affected clinics to full operation as quickly as possible,” said Bill Numbers, vice president of operations support and incident commander for disaster response and planning.
Following the devastation of Hurricanes Katrina and Rita in 2005, Fresenius Medical Care assisted more than 8,000 dialysis patients, 1,600 of whom were non-Fresenius Medical Care patients. In total, more than 100 Fresenius Medical Care’s clinics were affected by the storms, 80 of which were restored to operational status within the first 48 hours. RBT
Disaster Preparedness Advice on the Internet
Centers for Medicare & Medicaid Services recommendations: www.cms.hhs.gov/ESRDNetworkOrganizations/Downloads/EmergencyPreparednessforFacilities2.pdf
The National Kidney Foundation recommendations: www.kidney.org/atoz/pdf/disaster_prepardness.pdf
The Centers for Disease Control and Prevention recommendations: www.bt.cdc.gov/disasters/pdf/icfordialysis.pdf
Missouri Department of Health and Senior Services “Ready in 3”: www.dhss.mo.gov/Ready_in_3
The American Nephrology Nurses’ Association Disaster Preparedness Information Center: www.annanurse.org/cgi-bin/WebObjects/ANNANurse.woa/wa/viewSection?s_id=1073744053&tName=katrinaInfo
Preparing for Disaster for People with Disabilities and other Special Needs: www.annanurse.org/download/forms/applications/disaster/specialNeedsDisasterPreparation.pdf
Kidney Community Emergency Response Coalition Final Report on Disaster Response: www.nraa.org/Documents/Disaster/CoalitionFinalReport.pdf
The Renal Network, Inc., Emergency Preparedness and Disaster Planning: www.therenalnetwork.org/services/disasterplan.php