Facilities providing residential services to persons with traumatic brain injury (TBI) in coastal areas are potentially vulnerable to the devastating effects of hurricanes. While it is impossible to develop contingencies for all possible scenarios arising from a hurricane, investing the time and effort into a planning, preparation and practice process is a prudent endeavor. Persons with TBI represent an extremely vulnerable population, particularly in an emergency situation, due to the cognitive, physical, emotional and behavioral impairments stemming from injury. The consequences of moderate to severe TBI can impair the ability to recognize and respond to a weather emergency, and may complicate facility evacuation. Programs serving persons with TBI must plan for weather emergencies, conduct evacuation activities, and provide care during and after the event. Hurricane preparedness is now considered part of the standard of care and an element of best practice for residential TBI programs in coastal regions.
In this paper we reflect on two complete facility evacuations conducted in advance of major hurricanes (Rita, 2005 and Ike, 2008). The lessons learned, how the evacuations influenced changes in emergency preparedness plans, and the creative problem-solving process employed to address unanticipated needs will be reviewed. From our evacuation experiences, three themes emerged and will be illustrated through this narrative reflection. First, while preparing for a hurricane may appear to be a relatively straightforward administrative task, it is actually quite complex, requiring significant planning and forethought. Planning and preparation beyond what is recommended by licensing/ accrediting agencies is necessary. Secondly, while patient care and clinical service delivery are the primary tasks of rehabilitation and must continue following an evacuation, an equal measure of attention must be provided to staff. During and after an evacuation, staff may sacrifice attending to personal needs in order to respond to the emergency and/or to the needs of their patients, potentially placing them at risk for stress-related conditions. Finally, after emerging from the crisis, information and experiences (i.e., “lessons learned”) must be reviewed and incorporated into the hurricane preparedness plan. Lessons learned should be shared to benefit other facilities, and made available to researchers and policy makers interested in using the information to develop evidenced-based guidelines for hurricane preparedness.
DEVELOPING A BASIC PLAN
Developing a basic emergency preparedness plan involves critical components: a thorough review of licensing and accreditation standards addressing emergency preparedness, assessing the facility’s vulnerability to a hurricane, and assessing the patient population and resources available to manage them in an emergency.
Review of Licensing and Accreditation Standards
All states have an agency responsible for licensing residential facilities providing nursing, rehabilitation, long-term care, and assisted/supported living services. Licensing agencies require written evacuation plans to be filed annually, and notification provided to the agency in the event an evacuation is ordered. When evacuating, agencies require facilities to report the number of patients and staff evacuating, and their destination. The agency follows up with the facility after the emergency. (Licensing Standards for Assisted Living Facilities Handbook, 2009).
Many facilities providing medical, rehabilitation, vocational, and/or long-term care services to persons with brain injury also seek accreditation from an outside agency. The Commission on Accreditation of Rehabilitation Facilities (CARF), an accrediting agency for brain injury services, is responsible for developing standards for emergency preparedness. CARF standards require: 1) a written plan for weather and/or other event(s) specific to the geographic location of the facility; 2) contingencies for a complete facility evacuation, including the disposition of both staff and patients; 3) a test of the plan at least annually and an evaluation of the plan’s effectiveness and efficiency; and 4) staff to receive training regarding the preparedness and evacuation plan, including their specific roles and responsibilities (CARF Medical Rehabilitation Standards Manual, 2001).
Assess Vulnerability to a Hurricane and Community Response
TLC is located on Galveston Island in the southwestern Gulf of Mexico. The TLC facilities are approximately 9 feet above sea level and are situated behind the city’s protective seawall. However, assessing vulnerability to a hurricane requires more than determining the facility’s distance from the coast, its elevation, and hardiness of construction. It also requires knowledge of the community’s history with and response to hurricanes. For example, the type and accuracy of information available to the public during an emergency (i.e., local radio and television news, the Weather Channel, etc.) should be determined. Designated evacuation routes should be identified and the traffic patterns on those routes during evacuations investigated. The time required to restore basic services (power, clean water, hospital facilities, police and fire service, etc.) after an emergency event should be reviewed.
Assess the Patient Population and Available Resources
The last step in developing a basic hurricane preparedness plan is estimating the number of patients requiring evacuation and care, assessing the functional level and special needs of the patient population, and the resources available to manage that population.
Moderate to severe TBI often produces significant impairment in physical, cognitive, emotional, and behavioral functioning (NIH Concensus Statement, 1999). These consequences impair the ability to independently recognize and respond to an emergency situation and can complicate evacuation. Patients with physical impairments who require assistance evacuating (i.e., exiting a building, transferring into a vehicle, etc.), those patients requiring assistance with basic activities of daily living (ADL’s) such as feeding and self-administration of medications, and those with medical co-morbidities (i.e., high blood pressure, diabetes, a seizure disorder, allergy, swallowing problem, etc.) should be identified.
The resources required to conduct an evacuation and meet patient needs following the evacuation should be identified. Determine the number and type of vehicles (e.g., vehicles equipped with a wheel chair lift) required to transport patients away from the facility. Estimate the number of staff necessary to conduct an evacuation, and the types of staff required to care for the patient population after the crisis has passed (i.e., direct-care staff, nurses, therapists, etc.). Identify the adaptive equipment, medicines, special food, and other supplies (i.e., incontinence supplies, diabetic supplies, etc.) required to deliver care, and how those materials will be transported with the patient population. A primary evacuation route and an evacuation destination capable of housing the patient population, staff, and equipment/ supplies must also be identified.
TLC’s EMERGENCY PREPAREDNESS PLAN PRIOR TO RITA, 2005
The Transitional Learning Center (TLC) developed a basic hurricane preparedness plan as outlined in the previous section. The plan was reviewed and updated at regular intervals. However, over time a significant change occurred in referral and admission patterns and the functional level of the patient population, necessitating a revision in the emergency preparedness plan. The updated plan had to account for the multiple and complex needs of this patient population. The plan required the presence of nursing and clinical staff in the event of a facility evacuation.
A Team Approach to Evacuation
TLC developed a team approach to hurricane preparedness, evacuation, and recovery involving all facility personnel. Three evacuation/response teams were proposed, each with distinct responsibilities. Table 1 describes the primary responsibilities of each team. Team A was responsible for packing and transporting patients to the designated evacuation site, developing a care and activity schedule, and engaging the patients for 24-48 hours following the evacuation. When the emergency resolved, patients were transported back to TLC. If it was necessary to remain away from the facility for an extended period of time, Team B relieved Team A. Team B was responsible for continuing to engage the patients in the care and activity schedule for the next 24-48 hours. Once the “all clear” was given, Team B was responsible for packing the patients and returning to TLC facilities. Team C was engaged when the “all clear” was given. Team C prepared TLC facilities for resumption of normal operations. Team C was responsible for cleaning and organizing the facility, ensuring basic services were restored and operational (i.e., power, water, computer systems, alarm systems, etc.), and receiving the patients when Team B returned.
Team membership was required of every staff member. Staff was encouraged to select a team assignment consistent with their family situation, skills and experience. Requiring all staff to participate in hurricane preparedness, evacuation and recovery activities, and allowing staff to select the team assignment created a sense of equity, ensured “buy in” by all staff, and encouraged a sense of responsibility to the patients and TLC organization. When the preparedness plan was reviewed annually (prior to the beginning of hurricane season), staff was allowed to change team assignment if their status had changed since the previous year.
Table 1: Evacuation Team Responsibilities
- Following evacuation order, pack patients and transport to evacuation site
- Unpack patients; organize belongings and equipment in rooms
- Implement schedule of activities for patients; implement supervision schedule
- Continue to care for patients and engage in activities for 24-48 hours
- Travel to evacuation site and relieve Team A (if necessary)
- Continue to care for patients and engage in activity schedule for 24-48 hours
- Pack patients and transport back to TLC facilities when “all clear” is announced
- Travel to TLC facilities and prepare for resumption of normal operations
- Clean facility and grounds; ensure basic services are operational (power, water, etc.)
- Receive patients when Team B arrives at the facility
- Unpack patients and organize belongings and equipment in rooms
Additional Components of the TLC Emergency Preparedness Plan
Identification of a primary evacuation site.
A hotel north of Houston, Texas (about 60 miles inland) capable of accommodating a large group of patients and staff was selected as the primary evacuation site. The hotel was contacted at the beginning of each hurricane season (June 1st) and a bank of rooms for a group of 50 was “reserved” in the event an evacuation was necessary.
Pre-evacuation protocols were developed for specific departments in the event of a hurricane.
When a hurricane entered or formed in the Gulf of Mexico and Galveston was within the high probability strike cone, physical plant staff and designated facility support staff was assigned to monitor weather information and announcements from local authorities (i.e., local weather station, city and county offices of emergency management, etc). Physical plant staff was responsible for fueling all facility vehicles and for securing items that might move about in high winds (i.e., furniture, planter boxes, trash cans, etc.) and cause damage to the facility or injure patients and staff. Nursing and Residential staff was responsible for organizing patient belongings (clothing, adaptive equipment, etc.), preparing food for patients on special diets, and packaging medications. Case Management staff was responsible for contacting families and funding sources and informing them of a possible facility evacuation, reminding them of our evacuation destination, and allowing families an option to take their loved one home until the storm passed. Information Technology staff was responsible for securing computers, servers and other information technology.
Criteria for evacuating the facility and administrative authority.
Not all emergencies require facility evacuation. Risks are involved in evacuating persons with physical and cognitive impairments, and medical problems. Studies of nursing and assisted living facilities conducted after hurricanes Katrina and Rita indicated mortality was higher for frail elderly in facilities that evacuated in advance of a hurricane as compared to facilities that sheltered in place (Dosa, Grossman, Wede & Mor, 2007). TLC administration opted to follow recommendations from local authorities. Unless a mandatory evacuation was ordered, patients and staff would shelter in place. Only the TLC Administrator and Medical Director had authority to order a facility evacuation.
Rehearsal of a complete facility evacuation.
Research demonstrates practice is essential to hurricane planning and preparedness (Gebbie, Horn, McCullom & O’Hara, 2009; Slattery, Syvertson & Krill, 2009). In order for staff to participate in an evacuation rehearsal, and to ensure continuity of facility operations (i.e., therapy, billing, etc.), the evacuation drill must be incorporated into usual facility practices. TLC’s programs participate twice yearly in a three-day special activities camps. Camp attendance was used to rehearse a full facility evacuation. The location of the camp (“Camp-for-All”) is approximately 90 miles inland in Burton, Texas, about a 2-hour drive from Galveston. The majority of rehabilitation and long-term care patients participate in this activity. The camp is fully accessible and offers a range of adapted recreational activities. Participation in the camp requires packing three days of clothing, food for special diets, medicines, and necessary adaptive and durable medical equipment to provide care. It requires loading and transporting patients and their belongings to camp, unpacking, and engaging patients in an activity schedule. At the end of camp, patients must be packed and transported back to TLC. These same activities are required in a facility evacuation.
The elements in the emergency preparedness plan outlined above met or exceeded all state health licensing and CARF requirements. However, planning for and actually responding to a hurricane, as illustrated in the descriptions that follow, can be very different endeavors altogether.
HURRICANES KATRINA AND RITA, 2005 – LESSONS LEARNED
Hurricane Katrina, a powerful category 3 hurricane at landfall (winds 111-130 miles per hour), struck the Louisiana coast approximately 30 miles northeast of New Orleans on August 29, 2005. Katrina caused catastrophic property damage and killed 1,833 persons across 5 southeastern states (Carpender, Campbell, Quiram, Frances & Artzberger, 2006). Over 1,500 were killed in Louisiana. Most deaths resulted from storm surge, the extensive flooding caused by the wall of water preceding the eye of the hurricane. People over the age of 60 constituted the majority of storm-related deaths. A considerable number who perished were in residential care facilities.
Hurricane Rita – Inadequacy of Our Plan
Less than one month after Katrina made landfall near New Orleans, hurricane Rita formed in the Gulf of Mexico. As Rita tracked westward across the Gulf of Mexico, Galveston was placed within the high probability strike cone. The local and national media began re-broadcasting images of the destruction caused by hurricane Katrina. A few days prior to landfall, Rita grew into a powerful category 5 hurricane with winds in excess of 175 miles per hour and a predicted storm surge of approximately 18 feet. Meteorologists forecasted the storm surge would likely engulf the island of Galveston and inundate the area surrounding Galveston Bay. Houston, Texas would likely sustain severe damage from rising water, high winds, and heavy rain.
Based on this information, it was apparent our hurricane preparedness plan was inadequate. Though the plan met or exceeded standards established by the state health agency and CARF, certain aspects of the plan were inadequate for a category 5 hurricane. The plan did not move patients and staff far enough inland to avoid the storm surge and strong winds associated with a category 5 storm. The facility (hotel) identified as the primary evacuation site did not meet the patient needs. There were not enough beds to accommodate the patients requiring evacuation and the number of staff needed to provide care. Toilet and shower facilities were not accessible in all rooms. There were a limited number of washers/dryers to launder clothing and bed linens for incontinent patients. There were no cooking facilities to prepare special diets for patients with dysphagia, diabetes, and/or heart conditions. The hotel had little or no storage space for durable medical equipment, and no space for conducting group activities.
On Tuesday, September 20, 2005, just 4 days before landfall, TLC’s management team assembled and discussed options. The primary task before the management team was locating an accessible facility large enough to accommodate patients, staff, and equipment necessary to provide care. Facilities in Texas providing post-acute and long-term care services to adults with TBI were contacted. All facilities contacted offered assistance. The CORE facility (formerly Brown-Karhan), located a few miles west of Austin, Texas, was selected as it was the closest facility. The management team reviewed the remainder of the plan and agreed to follow established duties and role responsibilities outlined in team assignments, and to follow the other facility preparedness protocols. TLC’s Administrator and Medical Director issued the order to evacuate at 8 a.m. on Wednesday, September 21, 2005.
Unfortunately, media reports panicked the public. Approximately 2.5 million residents in the Houston/Harris County area began a mass exodus (Stein, Duenas-Osorio Subramanian, Post, Zuiener, Hoffman, & Feldman, 2009). Vehicles overwhelmed the roadways and within a few hours, all routes leading away from Houston were inundated with traffic. A trip across the Houston metropolitan area that generally took one hour required as many as 24 hours to complete. Service stations and convenience stores ran out of gasoline and basic staples such as snack food and bottled drinks. Lack of restroom facilities along evacuation routes resulted in unsanitary disposal of human waste, creating a potential public health hazard.
Hurricane Rita turned northeastward and missed the Galveston-Houston area, making landfall near the Texas-Louisiana border on September 24, 2005. Rita contributed to the deaths of 119 people, 113 of those in Texas. Sadly, only 6 of the deaths were attributed to the storm. The other 107 deaths were caused by activities related to the evacuation (Carpender, et al, 2006). As was the case with hurricane Katrina, the most vulnerable in the population, the elderly, the sick, and the disabled were the largest casualties of the evacuation.
Lessons Learned from Rita
The evacuation experience in advance of hurricane Rita evacuation provided TLC with a wealth of information, all consistent with the post Katrina-Rita evacuation literature (Department of Health and Human Services, 2006). The difficulties encountered included:
While the number of TLC vehicles was adequate to transport patients and staff, there was little space for equipment, food, medicines, medical records, clothing and other supplies. The trip to CORE, normally a 4-5 hour drive, required 12-14 hours. Staff and patients remained in cramped seating arrangements for the duration of the evacuation. Traffic density precluded exiting the roadway for a meal, stretch or bathroom break. Vehicles were separated in traffic resulting in a disorganized arrival at the CORE facility.
Communication with staff and families was difficult. Families and staff had been provided the number to the hotel in Houston, the original evacuation site, not the number to the CORE facility. Staff had provided supervisors with the phone number corresponding to a location in or near Houston. Most staff, however, opted to travel further inland and was not at the number provided. Cell coverage was “spotty” at best, making it difficult to contact families and staff in order to provide current contact information.
Care for Patients and Staff
Patients and staff were spread over three of the CORE campuses, restricting the implementation of planned care and activity schedules. Team B staff were unable to relieve Team A due to congested roadways and fuel shortages. Staff quickly began showing signs of stress. Many were unable to sleep, most were working long hours providing direct care, and all were concerned about family and property.
The management team was assembled and established a very basic daily activity schedule around meals, medicine administration times, and ADL activities. Collaboration between the host facility and TLC allowed for CORE staff to rotate into the activity schedule and care for TLC patients. This collaboration allowed TLC staff brief periods away from patient care duties to rest, sleep, exercise, read, or leave campus. A reliable land line was accessed and family members of patients were contacted. A communication schedule was established allowing families daily phone contact with their loved one. The management team continued to meet daily to ensure staff needs were met.
Team A staff and patients returned to TLC facilities on Monday, September 26, 2005. Per the emergency preparedness plan, Team C staff cleaned and organized the facilities, and received patients. Within a week of returning, staff was debriefed and changes to the emergency preparedness plan were proposed.
Not all aspects of the plan were revised. The staff orientation and review of the emergency preparedness plan at the beginning of each hurricane season (i.e., June 1st), phone trees and the team approach to evacuation, and the protocols developed to
prepare the patients and facility for evacuation remained in the plan. The responsibility of case management to contact families and funding sources prior to evacuation, the criteria for evacuating, and administrative authority for ordering an evacuation remained in the plan.
Camp-for-All, the facility hosting biannual weekend activities camps for our patients, was identified as the primary evacuation site; CORE remained the back up evacuation site.
A large, covered utility trailer was purchased to transport food, clothing, medical records, and equipment. Primary and secondary evacuation routes were identified. Maps displaying evacuation routes, and locations of fuel, food, and medical care on the routes were laminated and placed in vehicles. A “preparation team” and a “communications officer” were proposed and added to the plan. These team members were to leave immediately when the evacuation order was given and ensure the primary evacuation route was clear, to prepare the primary evacuation site for arrival of the patients and staff (i.e., room/bed assignments, placing linens on beds, unloading equipment, etc.), and to communicate with families and staff.
Phone and web-based messaging was developed, allowing families and staff to log-on to the TLC web-site, or call a phone number to access updated information about the status of staff and patients, and to receive instructions.
Caring for Patients and Staff
A simple schedule of activities around meals, medications and ADL’s that could be quickly implemented upon arriving at the evacuation site was developed. Vehicle and room assignments would be decided prior to evacuating. A staff rotation schedule would be developed upon arriving at the evacuation site to prevent staff burn out.
The updated hurricane preparedness plan addressed all the shortcomings (i.e., “lessons learned”) identified from the hurricane Rita evacuation. The revised plan was rehearsed annually, and the plan was reviewed with all staff at the beginning of each hurricane season. Staff was allowed to change team assignment at the beginning of the hurricane season. Revisions to plan were not put to the test until 2008.
HURRICANE IKE, 2008 – LESSONS LEARNED
In early September, 2008, hurricane Ike entered the Gulf of Mexico. Though criteria for evacuating had not changed, the decision to evacuate was difficult. The extreme conditions experienced by patients and staff in 2005 while evacuating in advance of hurricane Rita, and a rapidly changing path as Ike tracked across the Gulf of Mexico were important considerations. Sheltering in place was preferred, if possible.
Mid morning on Thursday, September 11, 2008, a mandatory evacuation order was issued by Galveston’s mayor. TLC’s management team met to review the evacuation plan. No changes were recommended. TLC’s Administrator and Medical Director issued the evacuation order at 7 a.m. on Friday, September 12, 2008. The “prep team” departed in advance of patients and Team A staff, and prepared the evacuation facility for arrival. The main evacuation group arrived approximately two hours after leaving Galveston. By early afternoon, a schedule of activities had been developed, a staff rotation schedule was in place, and the communications officer had contacted families announcing our safe arrival at the evacuation site. The changes to our evacuation plan following hurricane Rita resulted in a flawless evacuation.
Hurricane Ike - Inadequacy of our Plan
Unfortunately, unlike Rita, hurricane Ike did not make a turn to the northeast prior to landfall. In the early hours of Saturday, September 13th, the eye of hurricane Ike struck the east end of Galveston Island. Winds in excess of 100 miles per hour and a storm surge of over 13 feet devastated the island. TLC facilities sustained severe damage from rising water. A return to Galveston was not possible.
While lessons learned from hurricane Rita resulted in significant changes in the hurricane preparedness plan, it did not account for a disaster of this magnitude. TLC’s management team was assembled and options discussed. The management team opted to temporarily relocate patients and staff to a “sister” facility recently opened in Lubbock, Texas until other arrangements could be made. As Lubbock was a 12-hour drive from our evacuation site, a comprehensive travel plan was developed. Families and TLC staff were notified of the plan. Team B staff were contacted and a partial staff rotation occurred prior to departing for Lubbock.
After arriving in Lubbock, routines for patient care and a staff rotation schedule were established. Patients participating in rehabilitation were admitted to the Lubbock post-acute program. Long-term care patients were housed on a separate wing of the Lubbock facility.
Over the next 3 weeks, B and C Team staff rotated in and out of Lubbock, providing care to patients and allowing A Team members to return home. Administrative staff searched for a temporary facility near Galveston. In early October, space was located in a nursing facility in northern Galveston County capable of accommodating both rehabilitation and long-term care patients. One wing of the facility was leased for rehabilitation, a second wing for long-term care. Staff and patients returned to Galveston County in mid October, 2008, and rehabilitation and long-term care programming resumed in the leased space.
Lessons Learned from Ike - Unanticipated Staff Needs
Staff presented a number of unanticipated needs following hurricane Ike. Contingencies to meet these needs were not part of the hurricane preparedness plan prior to Ike.
Staff residing in Galveston was unable to return to their homes. Many staff could not afford the additional expense associated with leasing an apartment or renting a hotel room for an extended period. TLC provided a one-time cash advance for living expenses to staff impacted by hurricane Ike.
Staff on the A Team left personal vehicles at TLC prior to evacuating. These vehicles were damaged or destroyed in the storm. TLC allowed staff to use facility vehicles for transportation to and from work. TLC’s Administrator and Medical Director negotiated with a local automobile dealership to offer special pricing and financing to staff that lost vehicles in the storm. Staff offering personal vehicles for car pools received an allowance for fuel.
Staff required considerable reassurance regarding employment. TLC’s Board of Directors opted to repair the facilities on Galveston Island and resume rehabilitation and long-term care programming as quickly as possible. All staff employed at the time of the storm was retained. Though this information was enthusiastically communicated to staff, some opted to resign and seek other employment. This eventually created a temporary staffing shortage.
Something to do
Many staff, particularly some members of Teams B and C and those not providing patient care, were idle for several weeks following the storm, causing anxiety and provoking concerns about maintaining employment. Once Galveston was deemed safe for citizens to return, TLC staff was contacted and work crews were assembled. TLC staff cleaned facilities, discarded damaged furniture and equipment, and placed usable items into protective “pods”. Staff also helped inventory losses and damages for insurance claims. Staff assisted with preparing the temporary program location for rehabilitation and long-term care activities (i.e., purchasing supplies, setting up office and treatment space, etc.). Providing staff with opportunities to be productive was a crucial element in the recovery effort following the storm, and proved to be beneficial for staff retention.
Following the storm, staff was debriefed in an effort to determine what aspects of the emergency preparedness plan worked and those that did not. It was determined that all of the changes made to the plan following hurricane Rita resulted in an orderly and efficient evacuation. The changes in the communication systems allowed B and C Teams to be fully engaged in evacuation and recovery activities.
Lessons learned from Ike resulted in another significant revision of the hurricane preparedness plan.
Lease space for interim use
A contingency was developed for leasing space in the event TLC facilities were unable to be occupied following a future storm. This contingency involved making tentative arrangements with “sister facilities” (i.e., rehabilitation facility in Lubbock, nursing facilities in the Houston area), a strategy recommended by nursing facilities in Louisiana damaged from hurricanes Katrina and Rita (Dosa, et al, 2007).
Placement of patients after the storm
TLC Case Managers placed patients in other rehabilitation facilities following Ike to ensure continuity of care and rehabilitation. This case management duty was incorporated into the revised plan.
Meeting staff needs following the storm
Contingencies were developed to provide financial assistance to staff on an as-needed basis (i.e., for housing, etc.), providing TLC vehicles to transport staff to and from work, and providing a fuel reimbursement for staff offering personal vehicles for car pooling.
Contingencies were added to the plan to provide staff with information, reassurance, debriefing, productive activities, and stress management/resilience exercises immediately after the storm.
Facilities providing residential services to persons with TBI in coastal areas are potentially vulnerable to hurricanes. Thoughtful planning is required as persons with moderate to severe TBI represent a vulnerable population and are dependent upon staff to conduct evacuations and provide care during and after a storm. Hurricane preparedness is required by state licensing and accreditation agencies, and is considered an element of best practice. Standards require written preparedness plans specific to the type(s) of emergencies that might occur given the geographic location of the facility. Standards also require the plan to account for staff and patients in the event an evacuation is necessary, and to provide education and training to facility staff.
However, despite mandates from licensing and accrediting agencies, not all facilities have a plan. Following hurricanes Katrina and Rita in 2005, it was determined that several nursing facilities and assisted living facilities were without an evacuation plan (Carpender, et al., 2006). Even when plans are in place, not all staff knows about them. A survey conducted in 2005 found that many health care professionals had limited awareness of their facility’s emergency plan (Gebbie, Silber, McCullum, and Lazar, 2007).
Standards also require facilities to rehearse and evaluate evacuation activities. Research indicates that practice is essential in emergency planning and preparedness (Gebbie, et al., 2009; Slattery, et al., 2009). When possible, in order to ensure staff participation and continuity of facility operations, the evacuation drill should be incorporated into usual facility practices.
It is also important to review and revise the plan periodically, considering the current functional level of the patient population and resources required for an evacuation. Following hurricanes Katrina and Rita, it was discovered that some facilities contracted with the same bus or ambulance service for evacuation, causing an extreme shortage in vehicles to transport patients out of harm’s way (Carpender, et al., 2006).
The community surrounding the facility is another important consideration when developing or revising an emergency preparedness plan. Recent reports indicate that enhanced weather predictions, as well as improved construction standards and the placement of man-made barriers (e.g., seawalls) create a false sense of security among residents of coastal communities vulnerable to hurricanes (Carpender, et al., 2006). As was seen in the chaotic evacuation in advance of hurricane Rita in 2005, overdevelopment in coastal regions and sources of information received by residents regarding an approaching storm can affect traffic patterns and efficiency of evacuations (Stein, et al., 2009).
Noticing and responding to staff needs is yet another consideration for hurricane planning. During an emergency situation, staff is likely to focus on the crisis or needs of their patients, rather than attending to personal needs. Exposure to stress brought on by physical exhaustion, lack of sleep, and concerns about family and property can create burnout and may increase risk for developing post-traumatic stress disorders (Brandt, Fullerton, Saltzgaber, Ursano & Holloway, 1995). Our experiences during and after evacuations demonstrated the benefits of providing staff with information, reassurance, and productive activities (“something to do”). Conducting debriefing sessions and management/resilience exercises immediately after the crisis proved beneficial to our staff. These interventions have also been suggested for rescue and health care workers who respond to disasters (Brandt, et al., 1995).
In conclusion, our experiences suggest that preparation beyond what is required by the standards is necessary. While the planning process appears to be relatively straightforward, actually responding to an emergency is another matter altogether. Though the emergency preparedness plans prior to Rita and Ike met or surpassed state health and CARF standards, both were inadequate to meet the challenges of the crisis at hand. In both instances the plans failed. Relying on the wisdom and experience of the TLC leadership, and the creativity and flexibility of the staff was required to overcome shortfalls of the plans. We recommend contemplating a worst case scenario and developing contingencies accordingly.
Brandt, G.T., Fullerton, C.S., Saltzgager, L., Ursano, R.J. & Holloway, H. (1995). Disasters: Psychologic responses in health care providers and rescue workers. Nord J Psychiatry, 49, 89-94.
Carpender, S.K., Campbell, P.H., Quiram, B.J., Frances, J & Artzberger, J.J. (2006). Urban evacuations and rural america: Lessons learned from hurricane rita. Public Health Reports, 121, 775-779.
Commission on Accreditation of Rehabilitation Facilities (2001). Medical Rehabilitation Standards Manual, Tuscon, Arizona.
Department of Health and Human Services, Office of the Inspector General (2006). Nursing home emergency preparedness and response during recent hurricanes. Washington, DC: Office of the Inspector General, US Department of Health and Human Services, Thousand Oaks, California.
Dosa, D.M., Grossman, N., Wede, T. & Mor, V. (2007). To evacuate or not to evacuate: Lessons learned from louisiana nursing home administrators following hurricanes katrina and rita. J Am Med Dir Assoc, 8, 142-149.
Gebbie, K.M., Horn, L., McCollum, M., & O’Hara, K. (2009). Building a system for preparedness: The NYCEPCE NEST experience. Journal of Public Health Management and Practice, 15 Supplement, 53-57.
Gebbie, K., Silber, S. McCollum, M. & Lazar, E. (2007). Activating physicians within a hospital emergency plan: a concept whose time has come? Am J Disaster Med, 2, 74-80. NIH concensus development panel on rehabilitation of persons with traumatic brain injury (1999). JAMA, 282, 974-983.
Slattery, C., Syvertson, R. & Krill, S. (2009). The eight step training model: Improving disaster management leadership. Journal of Homeland Security and Emergency Management, 6, 1-13.
Stein, R., Duenas-Osorio, L, Subramanian, D., Post, S., Zuiener, L., Hoffman, D. & Feldman, I. (2009) A comparison of the experiences of harris county residents during hurricanes rita and ike. http://www.media.rice.edu/images/media/0312_CCE_HurricaneIke_report.pdf. Accessed September 29, 2009.
Texas Department of Aging and Disability Services (2009). Licensing Standards for Assisted Living Facilities Handbook. http://www.dads.state.tx.us/handbooks/ls-alf. Accessed September 29, 2009.
Gary Seale is the Director of Clinical Programs at the Transitional Learning Center at Galveston. He has worked exclusively in post acute brain injury rehabilitation since 1990. Mr. Seale received his Master’s degree in Psychology from Jacksonville State University in Jacksonville, Alabama, in 1982. He is licensed in Texas as a Psychological Associate and Chemical Dependency Counselor. He is also a pre-doctoral student in the Rehabilitation Sciences division of Preventative Medicine and Community Health at the University of Texas Medical Branch in Galveston. Mr. Seale was instrumental in developing and implementing TLC’s hurricane evacuation plan and is responsible for training TLC and TideWay staff regarding hurricane preparedness. Mr. Seale was a member of the evacuation and recovery team during hurricanes Rita and Ike.
Brent E. Masel M.D. is the President and Medical Director of the Transitional Learning Center at Galveston. Dr. Masel received his Medical Degree from the Loyola University Stritch School of Medicine, and completed his postgraduate training from the University of Texas Medical Branch. He is a Board Certified Neurologist. After 16 years of private practice, he accepted his position with TLC. He holds clinical appointments at UTMB in the Departments of Neurology, Internal Medicine, Family Medicine, Physical Therapy and Occupational Therapy. He has conducted research and published in the areas of brain injury rehabilitation and virtual reality, as well as sleep abnormalities, metabolic abnormalities, and hormonal dysfunction after brain injuries. Dr. Masel is the President of the United Way of Galveston, and on the Board of Directors of the TIRR Foundation, the North American Brain Injury Society, and the Brain Injury Association of America. He is the recipient of the Lifetime Achievement Award from the Brain Injury Association of Texas and the Innovations in Clinical Treatment Award from the North American Brain Injury Society.
From Brain Injury Professional, the official publication of the North American Brain Injury Society, Vol. 6, Issue 4. Copyright 2009. Reprinted with permission of NABIS and HDI Publishers. For more information or to subscribe, visit: www.nabis.org.
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