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CHAPTER 20: Community Preparedness: Disaster and Terrorism
Joy Spellman
Gail A. Harkness
• For additional ancillary materials related to this chapter, please visit thePoint.
DOWN*
down it came down from the autumn sky down it came down & every one rose & wept in the city (my city) & some were flying & some were falling & some were running & some were burning where were you listening watching then? in the shattered earth? in the broken air? in the oily fire? in the tainted sea? where were you listening watching then when everyone rose & lookt at the sky lookt at the sky where they stood in my city & wept?
Jesse Glass
chapter highlights
• Public health nurses and disaster response
• Types of disasters
• Disaster management
• Public health response
• Role and responsibility of nurses in disasters
• Classification of agents
• Field response
• Skill building for field activity
objectives
• Identify disaster types.
• Explain the disaster planning process and nursing participation.
• Understand nursing participation in a disaster.
• Promote increased competency levels through the use of simulation technology and field drills, and exercises.
• Differentiate between biologic, chemical, and radiologic agents and response to exposure.
• Describe the public health response.
key terms
After-action report: Retrospective analysis used to evaluate emergency response drills.
Decontamination: Process of cleaning to remove biologic, chemical, or radiologic agents.
Evacuation: Moving people from a dangerous place to safety.
Incident command system (ICS): Common organizational structure implemented to improve emergency response.
Invacuation: Moving people from one area to another within the same facility.
National Response Framework (NRF): Framework that guides how the nation conducts all-hazards incident response.
National Incident Management System (NIMS): Structured, flexible framework that guides the response to disasters at all levels of government, the private sector, and nongovernmental organizations.
Personal protective equipment (PPE): Clothing and/or equipment used to protect the body from injury and illness.
Point of distribution (POD): Centralized location where the public picks up emergency supplies following a disaster.
Real time: The actual time in which something occurs.
Scenario: The sequence of possible events or circumstances.
Shelter in place: The protective action of taking cover in a building.
Simulation: The imitation of the features of an object or anticipated response.
Surveillance: A process to document and track changing information to prevent injury and illness.
Terrorism: The use of threats and/or violence to intimidate or coerce society for political purposes.
Case Study
References to the case study are found throughout this chapter (look for the case study icon). Readers should keep the case study in mind as they read the chapter.
After September 11, 2001, emergency management departments in the United States began to develop disaster response plans that called for a multidisciplinary, team-training approach. Focusing on biologic, chemical, and radiologic agents not normally seen in practice, local health department personnel, including public health nursing departments, became active participants. Although well versed in infection control, disease prevention, and health promotion activities, nurses expressed concerns about clinical skills needed to conduct field triage when dealing with agents outside the scope of their day-to-day practice.
Geoff, a nurse educator at New Jersey’s Public Health Nurses Association, has played an active role in providing education and hands-on experiences involving disaster-based scenarios among community-based nurses throughout the state. Nurses require more specific knowledge about harmful agents and situations not usually seen in their practice. With state support, the Public Health Nurses Association, with Geoff’s leadership, decides that a certificate on biologic, chemical, and radiologic terrorism will be offered with expanded content that will build new skill sets needed in a field response. Lessons learned from the response to the aftermath of Hurricane Sandy along the coast of New Jersey in November 2012 will be incorporated into the certificate curriculum.
The goal of the 40-hour course is to provide community and public health nurses with an introduction to a new practice dimension. Geoff decides to continue to incorporate human simulation technology in a field exercise setting that will stimulate critical thinking capacity, sharpen decision-making skills, and apply knowledge in a safe, nonthreatening, real-time field setting. The human patient simulators (HPS) are programmed with realistic agent-specific crisis scenarios that represent a variety of disasters of increasing complexity, threat, and pressure. Participants will develop emergency policies, plans, and procedures to ensure an effective response. Based on evacuation activities during Sandy, Geoff will include a module on preparedness operations while working with diverse communities. The program will be delivered in the spring, followed by an emergency exercise designed to test the capability of a large city’s response to a deliberate chemical attack. The community and public health nurses enrolled in the course will be key players in the planning, execution, and evaluation phases of the drill.
The only difference between reality and fiction is that fiction has to make sense.
Tom Clancy
Public health nurses have been responding to disasters for more than a century. Historically, nursing evolved from the actions taken by Florence Nightingale in the Crimean War. Long before the nursing process was theorized, researched, and established as part of the nursing profession, Nightingale used her skills of observation and critical thinking to improve health outcomes. McDonald (2001) has suggested that Nightingale implemented principles of evidence-based nursing at that time. As she strolled through hospital wards, Nightingale was actually documenting environmental conditions and their impact on clients she was charged to keep well. Nightingale’s analysis of health-related statistics, used to track outcomes, introduced epidemiology to the healthcare setting (see Chapter 6). Since that time, the public health nurse has continued to expand competencies by utilizing interventions that are enlightened by an evidence-based approach to improve population health. With a public health nursing workforce that understands and implements evidence-based public health practice, local health department officials and policy-makers will see the benefits of decision-making during a disaster. The Healthy People 2020 initiative issues a call to action “to strengthen policies and improve practices that are driven by the best available evidence and knowledge” (Healthy People, 2020). Additionally, the Patient Protection and Affordable Care Act of 2010 mentions “evidence based” throughout the document and will provide $900 million in funding to communities to implement the practice in an effort to improve population health (Patient Protection and Affordable Care Act, 2010).
Community and public health nursing has a broad scope of practice. For example, population-based practice has a narrow focus (e.g., six students with diabetes in a middle school) or a broad one (e.g., a potential H7N9 pandemic). Managing a client load of six certainly seems reasonable. Doing the same within a county of 400,000 people is quite different. The role of nurses within the community is to assess the needs of the populace and ensure that service breaches are addressed. Nurses accomplish this by calling on existing agencies and institutions to find ways to serve the needs of the citizens. Collaborative effort is a significant part of response. For example, local health department nursing personnel, school nurse organizations, and volunteers from the Medical Reserve Corps (MRC) have worked in concert to provide in-school H1N1 immunization as well as engaging in surveillance activities. From that experience, public health nurses in New Jersey are working at putting the knowledge and skills gained from the 2009 pandemic into evidence-based policies that may be implemented during the next event. Jacobs, Jones, Gabella, Spring, and Brownson (2012) point out that when evidence-based tools are applied, evaluated rigorously, and shared, improvements in population health will yield measurable outcomes. A well-prepared cadre of community and public health nurses is essential to minimize the effects of both immediate and long-range disasters.
The aftermath of the destruction of the World Trade Center in 2001 identified a lack of trained leaders and workers in all areas of public health service. The event also stimulated a growing appreciation of those who respond to large-scale events. Increased competency in disaster response became a new dimension to nursing practice. The Centers for Disease Control and Prevention (CDC) has called for the mobilization of the public health workforce to ensure the training and education of communities across the nation regarding biologic, chemical, radiologic, and explosive device attacks. It is necessary to learn how to prepare for events that are difficult to imagine, and it is even more challenging to mount a response. Recent disasters in New Jersey and Boston illustrate the importance of having a coordinated, multidisciplinary response to a culturally diverse population.
There cannot be a crisis next week. My schedule is already full.
Henry A. Kissinger
EVIDENCE FOR PRACTICE
A “Ready and willing” (Alexander & wynia, 2003) survey asked physicians and nurses whether they would be willing to respond to a biologic, chemical, or radiologic disaster. The study revealed that although 80% of professionals polled were willing to act in response to such an event, only 20% believed that they had the knowledge and appropriate skills to respond with competency. This served as a stimulus for the development of educational programs for health professionals. In an effort to update the evidence of the willingness of health professionals to participate in a disaster response, Chaffee (2009) conducted a systematic review of literature addressing this issue. The review outlined the clinical and nonclinical factors (e.g., family situation) that influenced the physicians’ and nurses’ decision to participate, their perception of responder safety, and the nature of the incident itself. A follow-up to Ready and willing (Crane, McCluskey, Johnson, & Harbison, 2010) shows that classroom study and field exercise participation among community-based nurses, physicians, and pharmacists resulted in a significant increase in their ability and willingness to respond effectively in a disaster.
What kind of data does Geoff gather in his disaster training needs assessment?
How can these new findings affect the emergency planning process for healthcare facilities and the community at large? How will the needs of a diverse community be addressed in the new plan?
EMERGENCIES, DISASTERS, AND TERRORISM
Response to emergencies and disasters has been a part of the human experience since humans first walked on the earth. A nation’s capacity to respond to these threats depends in part on the ability of healthcare professionals and public health officials to rapidly and effectively detect, manage, and communicate during an event resulting in mass casualties. Emergencies are considered events that require a swift, intense response on the part of existing community resources. Disasters are often unforeseen, serious, and unique events that disrupt essential community services and cause human morbidity and mortality that cannot be alleviated unless assistance is received from others outside the community. Disasters vary by (1) the type of onset (they often occur without warning), (2) the duration of the immediate crisis, (3) the magnitude or scope of the incident, and (4) the extent to which the event affects the community.
There are three types of disasters: natural, accidental, and terrorist attacks. Nature can wreak havoc when a tornado touches down or a hurricane obliterates a once-wide sandy beachfront. Natural disasters are widespread throughout the world. The 2010 catastrophic earthquake in Haiti, killing more than 230,000 people and injuring even more, remains in the news. Ongoing cholera outbreaks remain an issue on the island as a slow rebuilding and recovery process continues. Hurricane Sandy destroyed over 375,000 homes and displaced millions of people over a 6-month period beginning in November 2012, while an avalanche in northeastern Afghanistan destroyed a village of 200 in March 2012. The “Chelyabinsk Meteor,” as it has become known, resulted in 1,500 injuries caused by broken glass, burns, and the effects of shock waves as the asteroid fell to earth in northern Siberia in February 2013. To prove the point that natural disasters can occur by many natural forces, a cyclone striking Madagascar created optimal conditions for locusts to overbreed, resulting in 50% of the country’s farmlands being infested by swarms (Foley, 2012). Accidents include human-made disasters such as the Chernobyl meltdown in the former Soviet Union, which remains a constant reminder of the devastating effects of such a radiologic event. The near meltdown that occurred in post-tsunami Japan in 2011 has been deigned to be a human-made disaster based on evidence that revealed faulty design elements in the placement of reactor cooling tanks. Terrorist attacks continue to occur throughout the world on a daily basis, and in the United States, the April 2013 Boston Marathon bombings reminds us to be prepared for the unexpected.
Natural Disasters
Natural disasters are the result of naturally occurring events that have an impact on the environment, the economy, and the people who live in the area. Examples include earthquakes, extreme heat, floods, hurricanes, landslides, tornadoes, tsunamis, volcanic eruptions, wildfires, and winter weather. All of these conditions are threats to health.
Although many natural disasters are not predictable, it is possible to assess the circumstances that increase vulnerability to a natural disaster ahead of time and take steps to prevent complications. For example, as reports of a strengthening tropical storm in October 2012 came in to New Jersey’s state incident command center, experts tracking the storm agreed that “Sandy” would soon assume full hurricane status. With 127 miles of ocean front coast and 10 counties exposed to coastal waters, a storm evacuation plan has been in place and exercised over the years. Previously identified sites to be used as shelters were activated 2 days before the hurricane made land fall. County and state health departments, the Red Cross, local and state law enforcement, and public health nurses worked closely to accept the storm victims and assess their needs. On-site triaging resulted in the transfer of many storm victims for hypothermia and complications from existing chronic illnesses. In this instance, rapid assessment of an impending natural disaster, resource identification, and activation of an often exercised scenario resulted in saving scores of lives. As public health practitioners gather evidence for practice, it is becoming clear that in many disaster scenarios, the displacement of people before, during, and after the event must be considered as plans are developed. In 2010, 45 million people were forced to flee their homes due to sudden-onset natural disasters (Halff, 2011).
PRACTICE POINT
Many natural disasters are anticipated, such as hurricanes, rising flood waters, and temperature extremes. Include these events when planning for emergencies—a response can begin before the onset of disaster. Become familiar with locally designated shelter sites.
Accidental Disasters
Accidental incidents, broadly defined, are those that happen as a result of circumstantial factors (e.g., road conditions, human error, and physical plant deterioration) and are usually not deliberate. For example, a truck containing a toxic chemical being transported on a major highway system overturns when the driver fails to negotiate a clearly marked warning of the steep incline of the exit ramp. Evacuation of the area takes place. “Accident” implies that the incident is uncontrollable and/or unpreventable, usually with a negative outcome. But, do accidents just happen? Or can they be prevented? Over time, epidemiologists have identified ways to prevent the negative outcomes of unanticipated events by improving preparedness and awareness training and education. For instance, research findings may suggest that road signage located well before the steep incline, or consistent driver evaluation, could prevent vehicle accidents, or at least minimize their severity.
Like natural disasters, accidents may also have an impact on the environment, cost millions, and affect the lives of those involved. The 2010 collapse of the oil rig in the Gulf of Mexico and the consequent destruction of a vast, sensitive ocean environment is a good example. Preparing for accidental disaster is difficult, largely because of the possibility of human error and the setting in which it occurs. Certainly, the accidental release of nuclear materials affecting 1,000,000 people may not be seen in the same light as a medication error on the part of a nurse. In both cases, assessment of vulnerabilities with subsequent correction, followed by implementation of a preventive action, might have prevented the accident. Forgetting to complete a task can also contribute to a disastrous situation. For example, during review of an evacuation of a long-term care facility as part of a mandatory yearly exercise, administrators find that contracts with medical transport companies were not renewed, making effective evacuation impossible. Simulation training, discussed later in this chapter, may be an effective tool to identify human error potential. Regular review of emergency plans and twice yearly tabletop or functional drills will also point out needed areas of improvement and gaps in competency.
EVIDENCE FOR PRACTICE
Carrier, Yee, Cross, and Samuel (2012) points out that given the fragmentation of the healthcare system, diversity of community stakeholders, and limited resources, it is becoming more challenging to maintain coalitions that are committed to preparedness planning and execution of those plans. The authors suggest that policy-makers might consider providing incentives that encourage more community-based practitioners and organizations to participate in the planning process. Although the development of planning documents is essential to preparedness activities, planning leaders might consider defining outcomes expected within the collaboration in the event of a disaster. Clear identification of roles and responsibilities as the process develops lends itself to effective response. By broadening the scope of participants in the planning process, details previously overlooked have a better chance to be included in the disaster response, preventing accidental injury to community members. Coordination within a wider community coalition assures a workable, relatable mass casualty scenario.
In New Jersey, the use of simulation supports an evidence-based approach to disaster planning by identifying methods to use empirical data in the decision-making process. This process will help emergency response planners to identify hazards and vulnerabilities through a wide variety of scenarios, learn responses to each, and develop principles or best practices that apply to a broad spectrum of disaster scenarios. Ultimately, the promotion of injury and disease prevention programs and practices will be enhanced.
Terrorism
Terrorism, such as that experienced in New York City and Boston, is relatively new to America but not to the rest of the world. Although there are difficulties in defining global definition of terrorism, the United Nations described it as “any action intended to cause death or serious bodily harm to civilians or noncombatants with the purpose of intimidating a population or compelling a government or an international organization to do or abstain from doing any act” (United Nations, 2013). As the risk of catastrophic disasters increase, so too, the need to mitigate suffering and physical damage from these events also increases (Koenig & Schultz, 2010). As of early 2013, there still is no single agreed-upon definition of terrorism that is accepted globally. Nevertheless, it can be stated that terrorism is the deliberate use of violence or the threat of violence to coerce others for political purposes. The main goals of terrorism are creating fear, causing casualties, and rendering sites unusable. Fear and intimidation are potent concepts for the human psyche to process. The threat potential for continued acts witnessed worldwide underlies the need to develop and maintain society’s response capabilities (Berkshire Publishing Group, 2011).
Part of this new world of completely improvisational terrorism is that there were codes of war that disintegrated in the face of terrorism.
Diane Sawyer
DISASTER PREPAREDNESS IN A CULTURALLY DIVERSE SOCIETY
It is important to integrate a community’s ethnicity, race, culture, and language into emergency preparedness response and recovery plans (Andrulis, Siddiqui, & Purtie 2011). Outreach to diverse members of every community is critical to assure effective, inclusive strategies to protect all citizens. Public health nurses are well versed in identifying vulnerable populations within the districts in which they serve. Efforts to assure that health professionals and emergency responders become more culturally competent have gained momentum in the past few years. An increasing awareness of inequities visited upon ethnically diverse communities has emerged since Hurricane Katrina hit the Gulf Coast early in the morning of August 29, 2005. The Office of Minority Health, U.S. Department of Human Services, has developed a Cultural Competency Curriculum for Disaster Preparedness and Crisis Response that offers continuing education for those looking to enhance their skills toward the provision of competent care in disaster situations (U.S. Department of Health and Human Services, 2009). The courses will be offered through 2015.
Culture is the learned knowledge of values and beliefs of a particular group that are passed down through generations. These belief systems influence a person’s view of the world, decisions made, and behaviors tied into those beliefs. The latest data collected in New Jersey has identified over 4 million non-white citizens, of a total population of 9 million, calling the state home. These numbers clearly illustrate the importance of addressing multicultural influences during a disaster. A person’s culture is a comforting and reassuring system at the best of times. The degree of community cohesion can be seen as a determinant in survivor support. For instance, a disrupted community will not be able to provide the same level of support as one that is viewed as cohesive (Rutgers University, 2012). Given the benefit of advanced warning as Hurricane Sandy fast approached the New Jersey coastline, public health leaders and emergency response teams identified designated shelters for specific coastal county residents in an attempt to try to maintain a neighbor-to-neighbor environment. Separated family members were given the opportunity to move to a shelter where they could reunite with family and friends.
Social and economic inequality plays a large part in all areas of life; however, special attention to minority and disadvantaged neighborhoods must be given during the planning process. By most accounts, the poor and disenfranchised live in the less-desirable sections of the city, and the dwellings they occupy are not as resistant to time and natural weather extremes. Public health nurses recognize that many immigrant populations are not only unfamiliar with existing community resources but are reluctant to disclose their immigration status for fear of deportation.
In developing an inclusive community preparedness plan, it is important to become familiar with those community institutions that can meet the mental health needs of a diverse population. Language, and the potential barriers it may present during a disaster response, must be considered as a first step when mounting a field intervention during an event. As part of state and local planning in New Jersey, colleges and universities have identified volunteers who will act as interpreters for specific ethnic communities. As planning progresses, identify who the cultural brokers are within a community. By establishing solid working relationships with trusted organizations, and various cultural group leaders, public health nurses can begin to educate the citizenry about plans, intended response, and community resources well before the beginning of a disastrous event. Invite leaders to participate in all phases of disaster preparedness, response, and recovery operations.
A committee of nursing researchers has formed to establish standards of practice for cultural competency to guide nurses in their practice across the world to provide “culturally congruent nursing care” (Douglas et al., 2009). These standards are applicable to all nursing disciplines but are especially useful to public health nurses whose focus is community and populations at large. Standard 12, “Evidence-Based Practice,” stresses the importance of implementing interventions that have proved successful among diverse populations. In terms of disaster response, although evidence is building within the scope of public health practice, nurse researchers have a fresh opportunity to test interventions used during the events surrounding Hurricane Sandy with a focus on the reduction of disparities in health outcomes among the poorest citizens.
Geoff decides to integrate evidence-based knowledge from his Hurricane Sandy experiences in 2012 into the preparedness certificate curriculum. Based on the multicultural makeup of the displaced population he cared for, he is asking each nurse participant to select two distinct cultural and ethnic groups from within the community he or she serves. What vulnerabilities, hazards, and special needs will you have identified during the community planning process? If an evacuation order is given, how will this message be conveyed to these sectors in the community? Cite specific and special needs these community members may need once transported to a shelter.
PRACTICE POINT
During any disaster scenario, identify yourself as a nurse immediately upon making contact with a victim. nurses are recognized globally for their caring attitude and competency in difficult times.
DISASTER MANAGEMENT
Disasters have a timeline, often referred to as a life cycle or phases. These include the preimpact phase (before), the impact phase (during), and the postimpact phase (after). Actions taken during these phases will affect the illness, injury, and death that occur following the incident. Although disasters vary significantly, the response to each is similar. All disaster response begins at the local level—all communities must be prepared for emergencies. The disaster management continuum illustrates the essential steps in the process (Fig. 20.1).
figure 20.1
The disaster management continuum. (Adapted from Veenema, T. G. [2009]. Ready RN handbook for disaster nursing and emergency preparedness [pp. 3–25]. St. Louis: Mosby Elsevier.)
Just as there are distinct phases of a disaster, so too are there phases of an emergency management response. These are preparedness, mitigation, response, recovery, and evaluation. It is important to remember that during the management of any disaster, the activities carried out will frequently overlap phases. During a disaster, duties and their associated activities often cross boundaries in order to complete a task at hand.
Preparedness
Disaster preparedness plans are action plans developed in anticipation of disaster scenarios, providing a framework for response to emergency situations. They are proactive planning efforts that provide structure to a disaster response before it happens. In an all-hazards event plan, the response must be a coordinated community effort. This means engaging members of the community in ongoing preparedness activities. Working relationships can be strengthened by formalizing mutual aid agreements with regional health, police, and fire departments; volunteer organizations such as the Red Cross and other local planning groups; healthcare organizations; schools; and state response coordinators.
To ensure a successful response, steps must be taken before any incident, however minor, occurs. In this process, the risk for a given disaster is assessed, and the potential impact is evaluated. Planning for disasters involves data collection in three areas: (1) identification of hazards, (2) analysis of vulnerability, and (3) assessment of risk. The effectiveness of the disaster plan is only as good as the data that underlie the planning efforts and the assumptions (Veenema, 2012).
The identification of all existing and potentially dangerous situations before disasters occur is the first step in planning for an effective response. The types and combination of hazards are unique to a community. They may involve propensity for natural disasters, chemical or radioactive spills, transportation accidents, congregation of large groups of people, and numerous other situations. Different circumstances result in different types of injuries or illness, damage, and disruption of communication and transportation. Gathering historical data about previous disasters is helpful, and proven successful nursing interventions can be noted in the growing practice of evidence-based public health. Aerial photography, satellite imagery, wireless remote sensing devices, and geographic positioning systems are tools commonly used in hazard identification. Computer-generated pluming software is a proven means of indicating the direction in which a wind-driven chemical release is heading. Once the hazards are identified, the extent of damages, interruption of services, and threats to health can be estimated. This information can be used in designing a community emergency plan.
Analysis of Vulnerability
The community disaster planning team should also identify those groups of people who are most likely to be affected in a variety of disaster events. Vulnerability varies according to the type of hazard involved, and people who are most likely to suffer injury, death, or loss of property should be identified for each hazard. In addition, the ability or capacity of the community to respond to the effects of specific disasters should be assessed. Vulnerability analysis predicts who will be affected the most and identifies community resources that are available for a response. To keep emergency plans up-to-date, population and environment changes need to be documented with changes made to the plan accordingly.
Assessment of Risk
Using the comprehensive data gathered from hazard identification and vulnerability analysis, the probability of adverse health effects due to a specific disaster can be calculated. This is often represented as a low, medium, or high risk. In this process, the resources of the community that would reduce the impact of a given hazard should be identified and plans made to strengthen those resources if necessary. Disaster prevention measures may be instituted that involve the removal of identified hazards, relocation of at-risk people away from the hazard area, provision of educational materials, institution of sensors, and development of community early warning systems.
National Response Framework
When the scope of a disaster extends beyond the capability of local and state governments to respond, the federal government is asked to provide assistance. The National Response Framework (NRF), established by the U.S. Department of Homeland Se
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