Public Health Nursing: Role in Disasters Flashcards
planning process for disasters: reasoning and steps
Adequate disaster preparedness and response is essential
Delivery of life-saving interventions
Optimization of population health outcomes
Step 1 – Form a team
Step 2 – Understand the situation
Step 3 – Determine the Goals and Objectives
Step 4 – Plan Development
Step 5 – Plan Preparation Review & Approval
Step 6 – Plan implementation and Maintenance
why do we plan?**
EVERYTHING SEEMS TO GO A LITTLE BETTER WHEN WE PLAN
ADDS ORGANIZATIONS AND STRUCTURE TO A CHAOTIC
SCENARIO.
PLANS OFTEN EXISTS BUT DOES NOT MEAN THAT IT IS
PERFECT, BUT IT IS CONTINUOUS
components of disaster preparedness**
prevention
mitigation
preparedness
response
recovery
what is a disaster
An occurrence causing widespread destruction and distress; a catastrophe.
what is a mass casualty event
A catastrophic event that overwhelms local resources. Multiple resources (federal &
state) are necessary to handle the crisis.
a disaster in a healthcare setting
A disaster is any situation that produces an immediate patient load greater than the ED has the capacity of handling without additional resources. Disasters are classified as external or
internal
health care setting roles in health care settings
Incident Command System
Medical Command Physician
Triage Officer
Media Liaison
MAJOR ROLES OF NURSE IN DISASTERS
Determine magnitude of the event
Define health needs of the affected groups
Establish priorities and objectives
Identify actual and potential public health
problems
Determine resources needed to respond
to the needs identified
Collaborate with other professional
disciplines, governmental and nongovernmental agencies
Maintain a unified chain of command
Communication
nursing and disaster
Respond quickly
Clinically competent to provide safe, appropriate, individual and population-based
care
in disasters, nurses tend to be:
First receivers of injured victims.
First responders to render emergency aid
and triage
Healthy People 2030: Disasters play a direct role in the objectives related to the following:
Environmental health
Food safety
Global Health
Health related quality of life and wellbeing
Immunization and infectious disease
Injury and violence prevention
Mental health and mental disorders
Occupational Safety and Health
Preparedness (New since 2020)
Public Health Infrastructure
IMPACT OF A DISASTER ON THE COMMUNITY
Population affected
Pediatric (childcare, etc)
Special Needs
Indigent
Displacement
Medications
Special equipment
Economic Impact
Social/Human Impact
Impact of the media
Resource Availability
Infrastructure Status
Long term Impact
HOW DISASTERS AFFECT COMMUNITIES
One Health and interconnectedness
Stress reactions in individuals
Exacerbation of a chronic disease
Older adult’s reactions dependent on health,
independence, income, and so on
Regressive behaviors in children
governmental responsibilities in disaster
Local government (first responders) Responsible for the safety and welfare of its citizens.
State government (Office of Emergency
Management) Involved when a disaster overwhelms the local
community’s resources.
Federal government (ASPR: Administration
for strategic Preparedness and Response)
A single department focusing on protecting the
American people
interagency body that reviews and
recommends countermeasures for ASPR to focus on.
Public Health Emergency Medical Countermeasures Enterprise (PHEMCE)
provides a coordinated, national approach to preparing health care systems to surge and overcome other complex challenges
associated with disaster health care.
ASPR’S Health Care Readiness Programs
use of ASPR Administration for strategic Preparedness and Response
leads the nation’s medical and public health
preparedness for, response to, and recovery from disasters and public health emergencies. ASPR collaborates with hospitals, healthcare coalitions, biotech firms, community members, state, local, tribal, and territorial governments,
and other partners across the country to improve readiness and response capabilities
a comprehensive, national approach to incident management that is applicable at all jurisdictional levels and across functional disciplines
National Incident Management System
National Incident Management System is intended to:
- Be applicable across a full spectrum of potential incidents, hazards, and impacts, regardless of size, location or complexity.
- Improve coordination and cooperation between public and private entities in a variety of incident management activities.
- Provide a common standard for overall incident management.
– Federal Emergency Management Agency (FEMA), 2020
mission is helping people before, during and after disasters, and our guiding principles help us achieve it.
FEMA
FEMA’s employees are committed to:
serving our country before, during and after disasters. Every day more than 20,000 emergency managers work to make our nation safer, stronger and more prepared
Established National Terrorism Advisory System
Threat alert: elevated or imminent threat
◦ FEMA published in-depth guide for citizen preparedness: Are
You Ready?
partnerships in disasters
Department of Homeland Security (DHS)
Federal Emergency Management Agency (FEMA)
Department of Health and Human Services
Centers for Disease Control and Prevention
Public Health System (PHS)
American Red Cross (ARC)/
International Red Cross
Other local, state, and federal agencies
Community partners
National Repository of medicine and
medical supplies
Supplies (Push Packages) can be sent
anywhere in the country within 12 hours
Each state has plans to receive and
distribute SNS resources
Strategic National Stockpile
manmade disasters**
Accidental
Deliberate
Chemical
Biological
Radiological
Nuclear
Explosives
natural disasters**
Earthquake
Tornado
Floods
Hurricanes
Blizzards
Wildfires
Tsunamis
Nuclear
Temperature Extremes
the deliberate release of viruses, bacteria, or other agents used to cause illness or death
in people, animals, or plants
Many of these agents can be found in nature and can be spread through the air, water, or food **
bioterrorism
Category A agents**
Anthrax *
Botulism
Pneumonic
Plague
Smallpox *
Tularemia
Viral
Hemorrhagic
Fevers
Ebola
Marburg
category A characteristics**
- Easily disseminated or transmitted person to person
- High mortality or major public health impact
- May cause panic or social disruption
- Requires special public health action
category B agents**
- Brucellosis
- C. perfringens
toxin - Glanders
- Q Fever
- Ricin Toxin
- Staph Enterotoxin
B - Water or Food
Agents
category B characteristics**
Moderately easy to disseminate
Moderate morbidity and low mortality
Requires specific enhancement of
diagnostic capacity and enhanced
category C agent examples**
Yellow fever virus * Influenza virus * Tuberculosis, including
drug resistant TB
* Rabies virus * SARS * Chikungunya virus * Tickborne
–* Hemorrhagic fever
viruses
–* Encephalitis complex
flaviviruses
agents of bioterrorism**
Anthrax
Smallpox
Plague
Tularemia
characteristics of anthrax
Caused by Bacillus anthracis bacteria found in soil
Incubation period 1-6 days (up to 60 days)
Inhalation anthrax is not spread person to person
Skin (Cutaneous)
Digestive (Gastrointestinal)
Lungs (Inhalation)*
Death can occur within 24 hours
Quarantine not necessary
No treatment in early stages: death approaches 100%
inhalation anthrax stages
Incubation 1-7 days
Initially mimics cold or flu
Brief period of improvement (hours)
Rapid progression to severe respiratory distress
treatment after exposure-breathing in spores
Cipro 500mg BID 60 days
Doxyclycline 100 mg BID 60 days
Vaccine available for military
two clinical forms of smallpox
◦ Variola major
◦ Variola minor
incubation period of smallpox
7-17 days
diagnosis of smallpox
Presence of virus, antigen, nucleic material, or
immunoglobulin in clinical specimens (blood and/or vesicles)
smallpox disease course
One of the first symptoms is usually a high fever
Next a rash…first on the tongue & in the mouth:
highly contagious stage
Rash develops into sores and spreads to all parts of
the body within 24 hours (starts on face)
**Sores become fluid-filled raised bumps, with an
indentation, may resemble a belly button: the most
distinguishing feature
Contagious until scabs have disappeared-usually 3
weeks
comparison of chickenpox vs smallpox
Smallpox
-fever - 2-4 days before rash
-rash appearance - pocks at same stage
-rash development - slow
-rash distribution - more pocks on arms and legs
-rash palms and soles - usually present
-death - usually 1/10 die
Chickenpox
-fever - at the same time as rash
-rash appearance - pocks in several stages
-rash development - rapid
-rash distribution - more pocks on body
-rash palms and soles - usually absent
-death - very uncommon
smallpox treatment
No proven treatment
Supportive therapy
◦ Intravenous fluids
◦ Analgesics/Antipyretic
◦ Antibiotics for secondary infections
◦ Cidofovir (being studied for antiviral
effects)
smallpox prevention
Vaccination
Isolation/decontamination
◦ Droplet and Airborne precautions for 17
days after a person’s exposure.
◦ Isolation/quarantine while individual is
infected.
◦ Considered infectious until scabs fall off.
– Scabs contain live virus.
prevalence of monkeypox
> 90,000 cases worldwide
Mortality 0.04%
US Deaths 54
symptoms of monkeypox
Febrile Prodrome 2-5 days before rash (not always recognized or not always occurring)
Fever
Headache
Respiratory symptoms
Lymphadenopathy
Lower GI general issues
Rectal bleeding
Conjunctivitis
characteristic rash of monkeypox
Texas resident shared on Instagram (Silver Steele name) photos since little was known about monkey pox. He sent them to the CDC so they could share.
-Similar to smallpox with centrifugal distribution
-Progresses from Macule-> Papule ->vesicle-> pustule-> crust -> desquamation
-Deep-seated firm well circumscribed with ventral umbilication
-Single state of development to a given site of the body
-Rash is often present on palms and soles
-Genital and perianal areas
-Lesions do not always disseminate to most sites of the body
-Number of lesions is lower
-21 days clears up
historical additional complications of monkeypox
Bronchopneumonia
Dehydration
GI disruption
Secondary infections
Sepsis
Encephalitis
Ocular infection & corneal scarring Skin scarring Death (11% in unvaccinated)
diagnosis of monkeypox
Highly infectious
Diagnosis by specimen of lesions
80,000 test per week
treatment of monkeypox
Many cases are mild and self-limiting (nonfatal)
Prognosis depends on
◦ Prior immunization status
◦ Health status
◦ Concurrent illness
◦ Comorbidities
Early 2000 panic smallpox vaccination, there may be some residual immunity
No current approved treatment for MPX
However antiviral and vaccines developed for smallpox can be use
◦ Antivirals Tecoviramax
prevention of moneypox
Vaccinating high risk individuals and those in contact via contact tracing.
Indications
High risk: immunocompromised, pediatrics, hx of atropic dermatitis or exfoliative skin disorders
pregnant or breast feeding, one of more complications (cellulitis, gastroenteritis, pneumonia)
vaccines of monkeypox
2 shot series
PEP and PrEP
Longer onset to protection, 2-4
weeks
Provided to jurisdictions and
federal entities
Jynneos Vaccine Injection
Prevention
EUA
Two intradermal injections four weeks apart
Max protection two weeks after dose
0.1 intradermal as effective as 0.2 IM
Prioritized for high-risk individuals and safe in HIV and persons with atopic dermatitis (different from previous smallpox vaccine)
ACAM2000 vaccine contraindications
cardiac, eye disease on topical steroids, immunosuppressed, atopic
dermatitis or other exfoliative diseases, pregnancy, HIV (regardless of immune status)
Vaccine Immune Globulin (VIGIV)
FDA licensed for treatment of vaccinia vaccination complications
No data - unknown effectiveness in MPX
May consider in severe cases of PEP
TPOXX Tecovirimat
FDA approved for smallpox for adults and pediatrics
No studies in MPX
Minor side effects
OraL or injectable
CDC holds EA protocols
Cidofovid (Vistide)
FDA approved for CMV retinitis in AIDS patients
Data not available but effective against OPV in vitro and animal trials
CDC holds EA for use in OPV (including MPX)
May be considered for severe disease
Renal toxicity RISK
Brincidofovir (CMD001, TEmbexa)
FDA Treatment approved for adults, children and neonates
Data not available
Not as much renal toxicity
respinder protection
Consider contact and droplet (not airborne) highly infectious
◦ N-95
◦ Face shield
◦ Gown
◦ Gloves
Limit aerosol generating procedures
Thorough cleaning between patient use
isolation
Strict isolation beyond COVID, do not
share anything
Own sink and shower, minimize any cross
contact
Bleach towels and sheets
Other people take care of pets
Use protective contact face mask to cover
lesions
Quarantine 4 weeks until all lesions are
healed
effects of disaster planning
◦Addresses problems posed by various events
◦Broad in scope
◦Addresses collaboration
◦Mutual aid agreements
–◦Agencies
–◦Organizations
Prevention (Mitigation and Protection)**
All-hazards mitigation (prevention)
◦ Reducing risks to people and property from natural hazards before they occur
Prevention against natural disasters
◦ Structural measures
◦ Protecting buildings and infrastructure
◦ Threats include forces of wind and water
◦ Nonstructural measures
◦ Land development restrictions
Prevention against human-made disasters
Heightened inspections
Improved surveillance and security operations
Public health and agricultural surveillance and
testing
Immunizations
Isolation
Quarantine
Halting of chemical, biological, radiological,
nuclear, and explosive (CBRNE) threats
what is mitigation**
Measures taken to reduce harmful effects
Prevention
Occurs before incident
Adjust the plan as needed
personal preparedness**
◦ Disaster kits for home, workplace, and car
◦ Disaster plan
professional preparedness**
◦ National Disaster Medical System
(NDMS) ◦ Disaster Medical Assistance Team (DMAT)
◦ Medical Reserve Corps (MRC) ◦ Community Emergency Response Team
(CERT)
reasons of preparedness
Proactive planning efforts
Evaluating potential vulnerabilities
Warning/looking for indicators
Location
Timing
Magnitude
community preparedness
National Health Security
Strategy (NHSS)
Disaster and mass casualty
exercises The National Exercise
Program (NEP)
Homeland Security Exercise
and Evaluation Program
Federal Emergency
Management Agency (FEMA)
response to disaster
First level: first responders
◦ Mobilization of local responders
◦ Fire department, law enforcement, public
health, and emergency services
National Response Framework (NRF)
◦ Emergency support functions (ESFs)
National Incident Management System (NIMS)
Response to biological incidents
◦ Biodefense programs
◦ BioWatch, BioSense, Project BioShield,
Cities Readiness Initiative, Strategic
National Stockpile (SNS)
response to focus on emergency relief
Saving lives
First aid
Minimizing and restoring
damaged systems
Care and basic life
requirements to victims
– Food
– Water
– Shelter
Role of the Public Health Nurse
First responder
Epidemiology and ongoing surveillance
Rapid needs assessment
Disaster communication
Disaster response ethics
Sheltering
PSYCHOLOGICAL STRESS OF DISASTER WORKERS**
Workers at risk for stress reactions
May not recognize the need for self-care
Symptoms may signal need for stress
management assistance
ANA Well-Being initiative:
Nurse’s Role in a disaster
Remember why you chose the nursing profession?
◦ To Care for others in their times of need
Our role as registered nurses is to understand your scope of practice
We will be called upon to care for the wounded, but also care for the mentally unstable patients as well.
Changing Care Expectations and Practices During a Disaster
Health care organization have to be prepared to
respond to acts of terrorism and public health
emergencies
Most plans assume care according to established standard of care
A mass casualty event could compromise these
plans
Adjustments in standards will ensure care will
save as many lives as possible
triage
Efforts need to focus on maximizing number of lives save
◦ Identify cause, protect staff and limit exposure
◦ Identify and treat those with a critical need and most likely to survive
◦ ED may be reserved for immediate-need patients
◦ Ambulatory patients delivered to alternate care sites
◦ Needs of current patients will become part of resource allocation.
scope of practice in disasters
Nurses may function as physicians
Physicians may function outside their specialty
Credentialing may be on an emergency or temporary basis
EMS could treat patients and not transport
equipment and supplies
may be rationed
if something breaks may not have ability to repair
disposable supplies may be refused
supplies could be contaminated
problems from inadequate staff
1
Staff may be scarce
2
Some equipment may not be used without trained staff to operate them.
3
Staff may not have access to facility if they do
not preplan
4
Concern for family needs versus work requirements
5
Staff could be directly affected (ill)
delays in care
Patients may be backlogged
Surgeries may be delayed
Radiology and laboratory services may be
rationed
Non-emergent care may not be given
Patients turned away
EMS reprioritizing responses and transportation
(zone car triage)
Primary care space for clinic may become
alternate care site or staff reassigned and
appointments cancelled.
treatment decisions
May be based on clinical judgment with the
lack of advanced technology
May not be made by specialist
Best use of available medications, supplies,
resources
Chronic care resources may be diverted
psychological impact of providers**
Acute event impact
Identification of staff not coping
Include mental health providers in team
Creative breaks
Staff communication with family
Surveillance of high-risk staff
Impact of inability to help given constraints on care
Forceful removal from duties
CISM essential
documentation in disasters
May be impossible to maintain
Regression to paper system from electronic
May not be able to obtain informed consent
May not be able to document care provided
Verbal handoffs important
Tracking of patients can be a challenge
death processes in disaster
Backlog
May not be able to accommodate cultural expectations toward death and handling of bodies
Temporary morgue
Difficulty identifying dead or confirm death
May have difficulty finding and notifying next of kin
Burial and cremation services may be overwhelmed
Standards for completeness and timeliness of death certificates may need to be lifted temporarily
6 guiding principles in disaster
- In planning for mass casualty event, the aim
should be to keep health care system
functioning and to deliver acceptable quality of
care to preserve as many lives as possible - Planning a health and medical response to a
mass casualty event must be comprehensive,
community-based and coordinated at the
regional or national level - There must be an adequate legal framework
for providing health and medical care in a mass
casualty event - The rights of individuals must be protected to
the extent possible and reasonable under the
circumstances - Clear communication with the public is
essential before during and after a mass
casualty event
◦ Public acceptance of event or situation that
deviates from standard practice - Post event clean up poses high risk for
additional injuries/illness - often lacks oversight
and organization
authority to activate the use of altered standard of health and medical care
Circumstances should be defined
Clarification to who can make the call and at
what level (site, community, region, state or federal)
Under what legal, statutory authority
Identify who assumes responsibility for directing emergency actions
Clarify relationship of autonomous institutions to the incident management system.
relevant laws in disaster
Emergency Medical Treatment and Active labor
Act (EMTALA)
Health Insurance Portability and Accountability
Act (HIPAA)
Federal Volunteer Protection Act
Good Samaritan Act
Medical and health care regulations
80 hr work week for medical residents
OSHA and workplace regulations
Building codes
Publicly funded health insurance
Human subject research laws
Use and licensure of drugs and devices
areas requiring adjustment
Liability of providers functioning with inadequate
resources
Certification and licensing
Scope of practice
Institutional autonomy
Facility standards
Patient privacy and confidentiality
Documentation of care
Property seizures
Quarantine and mass immunization
financial issues in disasters
COST TO PROVIDE CARE IN TRADITIONAL,
ALTERNATE SETTINGS, AND PRE-HOSPITAL
CARE SETTINGS
CREATING ALTERNATE CARE SITE IN SCHOOLS,
NEIGHBORHOOD CENTER AND HOTELS
TRAINING PROVIDERS (ADVANCE AND
JUST IN TIME)
STAGING DRILLS
REPAIRING PHYSICAL PLANT
TRACKING COST
SUPPLY PROCUREMENT
roles in mitigation
Participate in mass immunization programs
Surveillance and early detection
Education and public health initiatives
What can be done to help the infrastructure to survive / respond to any hazard?
recovery from disaster
◦ Focuses on stabilization
◦ Returning community to pre-impact status – make it better
◦ Rehabilitation
◦ Reconstruction
◦ Epidemiological surveillance is needed
websites for emergency management information
Ready.gov
Homeland Security
Federal Emergency Management Agency (FEMA)
NC Department of Public Safety – Emergency
Management
NC Division of Public Health
DHHS Department of Health and Human Services
goal of disaster triage**
To save the largest number of survivors from a multiple
casualty incident
why is triage difficult during a disaster**
As nurses we want to help everyone we can. We have a sense of helping, fixing and see positive results.
This is not always the case during a disaster.
The “walking wounded”, and by-standers are more likely to request or require more of your attention than the severely injured victims
red tag in triage**
those requiring immediate intervention and stabilization in order to preserve life or limb and still have a reasonable survivability index once stabilization has occurred
yellow tag in triage**
Victims will require treatment, which is minimal, and can be delayed without detriment. Will possibly need to be re-triaged for deterioration.
green tag in triage**
“walking wounded” patients will need medical treatment at some point
black tag in triage**
Patients are deceased or injuries are so extensive that they would not be able to survive with the care available.
Equipment and SuppliesWhat are things we could improvise with in a disaster???
Sticks for splints
Plastic bags with ice
Clothing for splints
Sheets for transport
Tables for backboards
How do healthcare facilities prepare for a disaster?
Medical Surge Capacity – the evaluation and care of a significantly increased number of patients beyond the typical capability of the establishment.
Disaster Drills (evidence – based)
Hazmat team training
Yearly competencies geared towards disaster preparedness
PRACTICE, PRACTICE, PRACTICE!
Just Remember: No matter how much we feel prepared for a disaster, there will always be chaos and uncertainty.
considerations for licensure
Be familiar with the nurse practice act of your state
Clarify the expectations for licensure and liability protection with the organization they plan to volunteer in.
Be familiar with your employer’s plans for staff who wish to respond and what their duty expectations are to their organization, both legally and ethically.
considerations for Good samaritan law
Good Samaritan laws generally provide liability protection to individuals for situations where emergency care is rendered using reasonable and prudent judgment for the circumstances.
Do not protect a provider working as an employee or as an organizational volunteer.
Do not protect against negligence or gross misconduct.
considerations for existing protections
No comprehensive national legal protection for healthcare providers working in the disaster cycle.
Patchwork
–Federal Volunteer Protection Act
–Federal Public Readiness and Emergency
–Preparedness Act
–State Volunteer Protection Acts,
–Model State Emergency Health Powers Acts
–State Public Health and Emergency Management Provisions
