Community-Wide Emergency Planning Involving Long-Term Care

The goals of emergency planning are to enable organizations and communities to care for themselves in the initial phase following natural or man-made disasters and to build on existing relationships so that each organization’s exposure to risk is minimized. This article explores the challenges of emergency planning and the strategies that can help long-term care organizations develop comprehensive emergency plans to meet real-world circumstances.

Emergency Planning
Requirements from private accreditors such as the Joint Commission on Accreditation of Healthcare Organizations and state and federal regulators have long mandated that nursing homes plan for emergencies. The Joint Commission, which has been actively involved in disaster preparedness for more than 30 years, increased its focus on emergency management two years before the September 11, 2001, terrorist attacks, and has worked even more closely with emergency-management experts and healthcare organizations since then to make this issue a priority. The resulting modified accreditation standards and overall guidelines, developed by multiple roundtables of experts, today better reflect the need for nursing homes and other healthcare organizations to be involved in community-wide planning, as opposed to confining planning solely to the single organization.

The Joint Commission’s Management of the Environment of Care (EC) standards require long-term care organizations to develop a management plan that ensures an effective response to emergencies, implement that plan, and help execute the plan by conducting emergency-management drills. These standards also require long-term care organizations to participate with the community in establishing priorities among potential emergencies, defining the organization’s role in the community’s emergency-management program, and linking with the community’s command structure.

While recent attention has focused on the emergencies created by Hurricane Katrina, Joint Commission standards emphasize the need to consider a variety of natural or man-made events that suddenly or significantly disrupt the environment of care or change demand for the organization’s services. This broad approach could encompass, for example, damage to the organization’s buildings and grounds caused by severe windstorms, tornadoes, hurricanes, or earthquakes; loss of utilities (power, water, telephones) because of floods, civil disturbances, accidents, or emergencies within the organization or in its community; or a bioterrorist attack, building collapse, or airplane crash that might occur in the community.

Long-Term Care’Specific Challenges
Nearly half of all nursing home residents (47.7%) have some form of dementia, and more than half of those age 85 and over (53.6%) have dementia, according to a 2001 report from the Agency for Healthcare Research and Quality (Available at: www.meps.ahrq.gov/papers/rf5_99-0006/rf5.htm). These facts create special challenges for long-term care organizations during an emergency.

For example, plans to address an influenza pandemic may include frequent handwashing by residents or wearing masks to prevent the spread of the infection through coughing or sneezing. However, a person with a cognitive impairment such as dementia may not be able to reliably carry out these standard precautions. Hurricane Katrina also showed that vulnerable populations such as nursing home residents can be at particular risk because they are so dependent on the good judgment of caregivers and organizational leadership. An immobile or cognitively impaired resident cannot independently escape rapidly rising floodwaters or even realize that such a danger is imminent.

Therefore, when working with community leaders to plan for emergencies, it is important for nursing home leaders to detail the special needs of their residents. Areas of consideration might include:

Communication. How will communication with residents be conducted during the chaos of an emergency? Those with dementia may not understand what is happening or may not react well to changes in routine. Also, how will information be shared with these residents’ families?

Basic personal care functions. Nursing home residents may not be able to adequately feed or hydrate themselves and will also need special assistance with toileting or other hygiene needs during an emergency and its aftermath.

Behavioral patterns. Nursing home residents may become disoriented and pose a danger to themselves or others if not in their usual secure environment. Community responders who may be assisting nursing home residents during an emergency should understand how to best aid and ensure the safety of this specific population.

Using an “All-Hazards” Approach
Joint Commission’accredited long-term care organizations, in collaboration with community leaders, typically conduct a hazard vulnerability analysis to identify the types of emergencies that may occur specific to the communities the organizations serve, and ways to plan for and respond to these. This approach allows organizations to consider a complete list of potential hazards. For example, is the nursing home in an area that is subject to weather emergencies such as blizzards in the winter, flooding in the spring, and tornadoes during various months? Are railroad tracks or highways located nearby that could be the site of a hazardous chemical spill?

The idea is to consider the effects that specific types of emergencies will have on the organization and the community. As part of this process, it is important to remember that one type of emergency may have a cascading effect. For example, the hurricane in New Orleans did not cause as much damage as initially feared, but the resulting levee breaches caused devastating flooding that led to the loss of power, communications failures, blocked escape routes, and so forth.

After compiling as complete a list as possible, the organization and the community together prioritize the emergencies based on the likelihood of each such occurrence. The areas of vulnerability that most demand community and organizational attention should be addressed in this plan. Response will require, for example, nursing homes to work in collaboration with emergency responders such as local fire and police departments and other healthcare organizations in the community, such as an acute care facility. By working together with these other experts, nursing homes can help ensure that the full spectrum of likely emergencies and contingencies has been considered and provided for. The collaboration also allows each disparate group to understand its role in a larger crisis. For example, road closures or curfews ordered by the municipality may interfere with the transit of essential nursing home staff or suppliers following a severe storm. Nursing homes should dialogue with the local police and public works authorities in advance regarding planning and communication to facilitate movement of essential staff and other resources during an emergency.

Working With the Community
Communities, and the healthcare organizations within them, must anticipate largely being on their own for several days following a disaster. Developing an emergency plan requires communities to determine who is responsible for planning, how to fund emergency readiness efforts, what exactly constitutes the planning and response processes, and how to coordinate with state and federal emergency-management resources. Nursing homes must also consider the impact of catastrophic disasters on their staffs. The potential loss of property or means of transportation, or the need to care for children or other vulnerable family members, may interfere with the ability of staff to report for duty during a disaster. Nursing homes should therefore proactively collaborate with staff to anticipate and adjust emergency staffing plans to ensure the delivery of essential services for residents, and work with local agencies to provide social support for staff as needed during and after disasters.

To aid healthcare organizations and communities in this process, the Joint Commission developed a free planning guide that provides 13 essential steps that can be used to establish an effective community-based emergency-management planning and response process. While long-term care organizations should work with government leaders on this process, it is also useful to consider the 13 steps within the context of emergency-management planning for the organization itself. The steps include:

• Define the community
• Identify and establish an emergency preparedness plan
• Determine the risks and hazards the community faces
• Set goals for preparedness and response planning
• Determine current capacities and capabilities
• Develop the integrated plan
• Ensure thorough communication planning
• Ensure thorough mental health planning
• Ensure planning related to vulnerable populations
• Identify, cultivate, and sustain funding sources
• Train, exercise, and drill collaboratively
• Critique and improve the integrated community plan
• Sustain collaboration, communication, and coordination

Detailed information about implementing these steps is available in the Joint Commission publication Standing Together: An Emergency Planning Guide for America’s Communities. The 2005 planning guide is the result of a two-year project that drew on expertise from two expert panels of frontline emergency responders, emergency preparedness planners, and public health and healthcare organization leaders. The free guide is available at www.jointcommission.org/PublicPolicy/ep_guide.htm.

The Joint Commission’s March 2003 white paper “Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems” also provides recommended strategies for developing community-wide preparedness. This free paper is available at www.jointcommission.org/PublicPolicy/Emergency_Preparedness.htm.

Conclusion
The Joint Commission is recognized as an organization that can bring disparate groups together to focus on a common goal. The great need for community-wide emergency preparedness is one such goal. And while no organization, and no emergency, is exactly like another, many similarities can be found in the way organizations successfully plan for and cope with emergencies. Long-term care organizations, along with other healthcare institutions, must take an active role in all community-wide emergency planning activities. Healthcare organizations can benefit from using Joint Commission standards to accomplish this formidable task, and the expert consensus provided in Standing Together: An Emergency Planning Guide for America’s Communities can pro-vide a template for maintaining focus on this important issue.

EC.4.10
The organization addresses emergency management.

EC.4.20
The organization conducts drills regularly to test emergency management.

EC.7.20
The organization provides an emergency electrical power source.

EC.7.40
The organization maintains, tests, and inspects its emergency power systems.

IM.2.30
Continuity of information is maintained.

IC.6.10
As part of community-management activities, the organization prepares to respond to an influx, or the risk of an influx, of infectious residents.

Effective July 1, 2006, revised standard EC.4.20 regarding emergency-management drills will require healthcare organizations to improve the planning and evaluation of these drills. This change is being made to help ensure that the field is conducting emergency-management drills rigorously and thoroughly. It is believed that there have been missed opportunities during drills to identify and improve weaknesses. The revised standards were derived from current literature on the characteristics of effective emergency drills and the input of two nationally recognized emergency-management experts. Based on this research, the revised standard emphasizes a continuous quality improvement approach to planning, conducting, and evaluating emergency-management drills.