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  • Disaster Nursing and Emergency Preparednessfor Chemical, Biological, and Radiological Terrorismand Other Hazards Second Edition EDITOR Tener Goodwin Veenema, PhD, MPH, MS, CPNP
  • About the EditorTener Goodwin Veenema, PhD, MPH, MS, CPNP, Preparedness” and collaborated with the American Redis an Associate Professor of Clinical Nursing, Assistant Cross to customize the ReadyRN curriculum for useProfessor of Emergency Medicine, and Program Director by the American Red Cross in educating and trainingfor Disaster Nursing and Strategic Initiatives at the Cen- American Red Cross health care professionals in pro-ter for Disaster Medicine and Emergency Preparedness viding health-related disaster and emergency responseat the University of Rochester School of Nursing and services.School of Medicine and Dentistry. Dr. Veenema is also Dr.Veenema’s ReadyRN Comprehensive CurriculumPresident and Chief Executive Officer of the TenER Con- for Disaster Nursing and Emergency Preparedness wassulting Group, LLC, which provides consultation and also published in 2007 as an innovative e-learning onlineworkforce development for emergency preparedness to course by Elsevier, and the companion ReadyRN Hand-federal, state agencies, and corporate organizations. She book for Disaster Nursing and Emergency Preparednesshas received numerous awards and research grants for will be published in fall 2007.her work, and in June 2004, Dr. Veenema was elected While at the University of Rochester, Dr. Veenemainto the National Academies of Practice and was se- developed the curriculum for a 30-credit Masters pro-lected as a 2004 Robert Wood Johnson Executive Nurse gram entitled “Leadership in Health Care Systems: Dis-Fellow. In 2006, Dr. Veenema was the recipient of the aster Response and Emergency Management,” the firstKlainer Entrepreneurial Award in health care. program of its kind in the country to be offered at a Dr. Veenema received her Bachelor of Science de- school of nursing. The program offers course contentgree in Nursing from Columbia University in 1980 and on the Fundamentals of Disaster Management, Chemi-went on to obtain a Master of Science in Nursing Admin- cal, Biological and Radiological Terrorism, Global Publicistration (1992) and a Master in Public Health (1999) Health and Complex Human Emergencies, Leadershipfrom the University of Rochester School of Medicine and Strategic Decision Making, and Communication inand Dentistry. In 2001, she earned a PhD in Health Ser- Disaster Response and Emergency Preparedness.vices Research and Policy from the same institution. Dr. Veenema has served as a reviewer to the In-Dr. Veenema is a nationally certified Pediatric Nurse stitute of Medicine Committee on the Review Panel forPractitioner, and worked for many years in the Pedi- the Smallpox Vaccination Implementation, Jane’s Chem-atric Emergency Department at Strong Memorial Hospi- Bio Handbook, 2nd Edition, and serves on the edito-tal (Rochester, New York). rial board for the journal Disaster Management and A highly successful author and editor, Dr. Veen- Response, sponsored by the Emergency Nurses Associa-ema has published books and multiple articles on tion. Dr. Veenema is an Associate Editor for the Journalemergency nursing and disaster preparedness. The first of Disaster Medicine and Public Health Preparedness,edition of this textbook, published in August 2003, re- sponsored by the American Medical Association.ceived an American Journal of Nursing Book-of-the-Year Dr. Veenema frequently serves as a subject-matterAward. expert for the National American Red Cross, multiple Dr. Tener Goodwin Veenema, in her role as Chief Ex- state health departments and nurses associations, asecutive Officer of the TenER Consulting Group, LLC, is well as the Registered Nurses Association of Ontario,the author and developer of “ReadyRN: A Comprehen- Canada. She is a member of the World Association ofsive Curriculum for Disaster Nursing and Emergency Disaster Medicine (WADEM).ii
  • Copyright C 2007 Springer Publishing Company, LLCAll rights reserved.No part of this publication may be reproduced, stored in a retrieval system, ortransmitted in any form or by any means, electronic, mechanical, photocopying,recording, or otherwise, without the prior permission of Springer PublishingCompany, LLC.Springer Publishing Company, LLC11 West 42nd StreetNew York, NY 10036–8002www.springerpub.comAcquisitions Editor: Sally J. BarhydtProduction Editor: Matthew ByrdCover Design: Mimi FlowComposition: Aptara07 08 09 10/ 5 4 3 2 1Library of Congress Cataloging-in-Publication DataDisaster nursing and emergency preparedness for chemical, biological, and radiologicalterrorism and other hazards / Tener Goodwin Veenema. – 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8261-2144-8 ISBN-10: 0-8261-2144-6 1. Disaster nursing. 2. Emergency nursing. I. Veenema, Tener Goodwin.[DNLM: 1. Disasters. 2. Emergency Nursing. 3. Terrorism. WY 154 D6109 2007]RT108.D56 2007616.02 5–dc22 2007012380Printed in the United States of America by Bang Printing
  • Preface It is quite probable that at some time in the future, nurses and skill set they will need to keep themselves, their pa- may be called upon to respond to a mass casualty event tients, and families safe during any disaster event. Once or disaster outside of the hospital. Advance preparation again, we have held ourselves to the highest standards of our national nursing workforce for such an event is predicted on the belief that mastery of the knowledge and possible. Every chapter in the book has been researched, skills needed to respond appropriately to such an event reviewed by experts, and matched to the highest stan- can improve patient outcomes. dards for preparing health professions’ students for ter- rorism, disaster events, and public health emergencies. I wrote these words in the spring of 2002 as I fin- The framework of the book is consistent with theished the summary section of chapter 9 (p. 199) in the United States National Response Plan, the National In-first edition of this book—3 1/2 years before Hurricane cident Management System, and is based on the Cen-Katrina would wreak its devastation on the communi- ters for Disease Control and Prevention’s (CDC) Com-ties of the Gulf Coast. When the first edition of the petencies for public health preparedness and the CDCbook was released, our country was still reeling from the Guidelines for response to chemical, biological, and ra-9/11 attacks and fearful of another outbreak of anthrax. diological events. This textbook will provide nurses withThese two events had resulted in an immediate aware- a heightened awareness for disasters and mass casualtyness of our lack of national emergency preparedness and incidents, a solid foundation of knowledge (educationalheightened vulnerability to disaster events. Health care competencies) and a tool box of skills (occupationalproviders were barraged by an onslaught of information competencies) to respond in a timely and appropriatefrom numerous sources (of varying quality) regarding manner.topics such as disaster planning and response, biologi- Since September 11, 2001, our national concerns forcal agents, hazardous materials accidents, the dangers the health and safety of our citizens has expanded toof radiation, therapeutics, and so forth. Resources on include additional hazards such as emerging infectiousthe Internet alone had increased exponentially. My own diseases (SARS, West Nile virus, avian influenza), theresearch on these topics had revealed that the existing detonation of major explosive devices, and the use ofdisaster textbooks were written by and for physicians nuclear weapons by countries unfriendly to the Unitedand public health officials. There was a major gap in the States. We possess a heightened awareness of the forcesliterature for nurses. Given the approximately 2.7 mil- of Mother Nature and the health impact on communi-lion nurses in this country, I found this to be not only ties affected by natural disasters. We continue to face aunacceptable but a major threat to population health growing national shortage of nurses and nurse educa-outcomes. Therefore, the genesis of the book was the de- tors, a health care system that is severely stressed finan-sire to fill this gap in the literature and to provide nurses cially, and emergency departments that are functioningwith a comprehensive resource that was evidence based in disaster mode on a daily basis. We have reason to be-whenever possible, and broad in scope and deep in de- lieve that these challenges for the profession will onlytail. We were very successful and the first edition was ex- intensify in the coming years. Nurses are challenged totremely well received, garnering an AJN Book of the Year be prepared for all hazards—to plan for pandemic in-award along with multiple additional accolades, and for fluenza, chemical, biological, radiological/nuclear, andthat I am eternally grateful. The book is currently being explosive (CBRNE) events, mass casualty incidents in-used nationwide by universities and schools of nursing, volving major burns, and surge capacity to accommo-hospitals, public health departments, and multiple other date a sudden influx of hundreds, possibly thousands, ofsites where nurses work. patients. In response to these concerns and the requests The second edition of this textbook has an equally of nurses across the country, I have added several newambitious goal—to once again provide nurses and nurse chapters in the second edition that serve to strengthenpractitioners with the most current, valid, and reliable the health systems focus of the book and to add a stronginformation available for them to acquire the knowledge clinical presence. v
  • vi Preface Since 2003, the Department of Homeland Security, This textbook continues to be a reflection of mythe Federal Emergency Management Administration love for writing and research, as well as a deep desire to(FEMA), the CDC, and other federal and nonfederal help nurses protect themselves, their families, and theiragencies have devoted significant resources to increas- communities. Disaster nursing is a patient safety issue.ing our level of national emergency preparedness. We Nurses can only protect their patients if they them-had made significant progress on certain fronts, but with selves are safe first. The second edition represents aregard to our level of workforce preparedness in the substantive attempt to collect, expand, update, and in-health professions, we have a long way to go. In the clude the most valid and reliable information currentlyyears since the first edition of this textbook was pub- available about various disasters, public health emer-lished, other nursing texts and educational resources gencies, and acts of terrorism. The target audience forhave been developed and published, and this author ap- the book is every nurse in America—making every nurseplauds these initiatives. There is much work to be done, a prepared nurse—staff nurses, nurse practitioners, ed-and it is personally rewarding to witness increased in- ucators, and administrators. The scope of the book isterest in disaster nursing as more nurses get involved. broad and the depth of detail intricate. My goal is to pro- As an emergency nurse and pediatric nurse practi- duce a second edition that represents a well-researchedtioner, I have worked in the field of disaster nursing and and well-organized scholarly work that will serve as aemergency preparedness for many years, with a focus on major reference for all our nation’s nurses on the top-promoting the health of the community and the health ics of disaster nursing and emergency preparedness. It isof the consumer by structuring, developing, and foster- my hope that nurse educators will be pleased to discovering an environment that is prepared for any disaster or the expanded organization of the book and the inclusionmajor public health emergency. I have lobbied for the of new chapters, case studies, and study questions. Theadvancement of the profession of nursing in the disas- insertion of Internet-based activities is designed to stim-ter policy and education arena, and I remain personally ulate critical thinking in students and to provide themcommitted to my work in preparing a national nurs- with the skill set to stay updated regarding these topics.ing workforce that is adequately prepared to respond to Ideally, this book represents the foundation for bestany disaster or public health emergency. This includes practice in disaster nursing and emergency preparedness,working to establish sustainable community partner- and is a stepping stone for the discipline of disaster nurs-ships that foster collaboration and mutual planning for ing research. Chapters in this book were based on em-the health of our community. It includes looking at inno- pirical evidence whenever it was available. However,vative applications of technology to enhance sustainable the amount of research in existence addressing disasterlearning and disaster nursing response. It means giving nursing and health outcomes is limited, and much workreflective consideration of the realities of the clinical de- remains to be done. The editor welcomes constructivemands placed on nurses during catastrophic events and comments regarding the content of this text.the need for consideration of altered standards for clini-cal care during disasters and public health emergencies. Tener Goodwin Veenema
  • AcknowledgmentsAs with the first edition of this book, I continue to pro- Services); Janice B. Griffin Agazio, PhD, CRNP, RNfess that researching, revising, designing, and deliver- (The Catholic University of America); Eric Croddy, MAing this book was a true labor of love—I enjoyed every (Monterey Institute for International Studies); and Garyminute of it! And like any effective disaster response, Ackerman, MA (Center for Terrorism and Intelligencethis textbook was a coordinated team effort. The second Studies). Thank you so much for your wonderful con-edition is significantly larger than the first—several new tributions and for your ongoing support of this book.chapters have been added, all of the content updated, Very special acknowledgments and many thanksand the clinical focus expanded. Additionally, the en- go to my international colleagues at the University oftire book has been mapped to the Centers for Disease Ulster—Pat Deeny, Kevin Davies, and Mark Gillespie,Control and Prevention’s competencies for public health and welcome to Wendy Spencer. These wonderful in-emergency preparedness—this represents nothing less dividuals were committed to providing a broad and il-than a Herculean effort. There are so many exceptional lustrative international perspective for the book. Theirindividuals, all over the country, who helped to make resultant chapter, Global Issues in Disaster Relief Nurs-this book a reality. ing, is evidence of their expert knowledge, extensive My special thanks must first go to each of the won- experience in the field, and dedication to internationalderful chapter authors who researched, reviewed, and collegiality. I will always remain grateful to each of themrevised their manuscripts, assuring that the information for their contributions to the field.contained within was valid, accurate, and reliable, and My thanks go once again to Jonathan Tucker, myreflected the most current state of the science. This was special contributor, for allowing me to reprint a portiona tremendous challenge given the highly transitional na- of his work from his wonderful book Scourge: The Onceture of many of the topic areas. The science was rapidly and Future Threat of Smallpox. It continues to be theevolving (and continues to evolve) and as with the first perfect segue into the Chemical and Biological Terrorismedition, the structure of many disaster and emergency section of the book.response systems was rapidly changing (and continues I wish to thank each of the case study authors andto change) during the year it was written. welcome the following new authors to the second edi- I would like to first thank my fabulous colleagues tion of the book. Thanks go to Ziad N. Kazzi, MD,who were chapter authors and/or contributors for the FAAEM, along with his colleagues Dave Pigott, MD,first edition and stayed committed to this project for the FACEP and Erica Pryor, RN, PhD at the University of Al-second edition. My very sincere thanks go to Kathleen abama at Birmingham Center for Disaster Preparedness.Coyne Plum, PhD, RN, NPP (Monroe County Depart- The quality of their work is incredible, as is their gen-ment of Human Services); Kristine Qureshi, RN, CEN, erosity in sharing it.DNSc (University of Hawaii); Brigitte L. Nacos, PhD and Another very special welcome and thanks go toKristine M. Gebbie, DrPH, RN, FAAN (Columbia Univer- Roberta Lavin (Health and Human Services) and Lynnsity); Lisa Marie Bernardo, RN, PhD, MPH (University Slepski (Department of Homeland Security). Robertaof Pittsburgh); Erica Rihl Pryor, RN, PhD and Dave Pig- and Lynn made sure that the descriptions of the Na-ott, MD, FACEP (University of Alabama); Linda Landes- tional Response Plan and all components of the federalman, DrPH, MSW, ACSW, LCSW, BCD (NYC Health & disaster program were as accurate as possible up to theHospitals Consortium); Kathryn McCabe Votava, PhD, time of publication. They are also two of the nicest andRN and Cathy Peters, MS, RN, APRN-BC (University of most generous individuals one would ever want to meet.Rochester); P. Andrew Karam, PhD, CHP (MJW Cor- Welcome and thanks go to Christopher Lentz, MD,poration); Joan Stanley, PhD, RN, CRNP (American FACS, FCCM; Dixie Reid, PA; Brooke Rea, MS, RN; andAssociation of Colleges of Nursing); Lt. Col. Richard Kerry Kehoe, MS (University of Rochester) for theirRicciardi, RN, FNP and Patricia Hinton Walker, PhD, chapter addressing the recognition and management ofRN, FAAN (Uniformed Services University of the Health burns and guidelines for disaster planning for a surge of vii
  • viii Acknowledgmentsburn patients. Dr. Lentz, as the Director of the regional Emergency Preparedness (University of Rochester, De-Burn/Trauma Center at the University of Rochester Med- partment of Emergency Medicine). Manish Shah, alongical Center, along with his wife Dixie Reid, are burn with his colleagues Jeremy, Charles, and Jonnathan,experts and tireless advocates for clinical excellence in contributed a comprehensive overview of Emergencythe care of the severely burned patient. Both Brooke Rea Medical Services as it currently exists in this country.(Burn Program Manager) and Kerry Kehoe (former Ad- This well-designed and well-organized chapter was aministrator Division of Trauma & Burn) are graduates of wonderful new addition to the book. John Benitez isthe Leadership in Health Care Systems in Disaster Re- Director of the Western New York Regional Poison Con-sponse and Emergency Health Care Systems, and so it trol Center, who along with Sharon Benware, RN, con-is an even greater pleasure to be able to include them in tributed to the chapter addressing chemical agents ofthis edition of the book. Brooke’s talents and leadership concern.skills were clearly evident in her effort to produce this I want to express my continued appreciation andchapter, and I send her my special thanks. sincere gratitude to Lisa Bernardo, Erica Pryor, Kris- A sincere welcome and thanks go out to two new tine Qureshi, and Kathy Plum for their elegant contri-authors and former students of mine, Tara Sacco, MS, butions, for their ongoing support and encouragement,BS, RN and Jennifer Byrnes, MLS, MPH (University and for their willingness to make recommendations thatof Rochester). Tara is a graduate of the Leadership in strengthened the content of the book. I have the ultimateHealth Care Systems program in Health Promotion and respect for each of you, and I am sincerely grateful forHealth Education; Jennifer is a graduate of the Mas- our ongoing relationships!ter’s in Public Health program. Both are talented re- Special thanks go out to my wonderful friends andsearchers and writers, and it is my guess that you will colleagues, Diane Yeater, Associate Director for Disasterbe hearing more from them in the future. Their chapters Health Services and to Nancy McKelvey, Chief Nurseon Traumatic Injuries Due to Explosions and Blast Ef- at the American Red Cross, National Headquarters infects, and Emerging Infectious Diseases (respectively) Washington, DC. Thank you for your contributions andbroadly expanded the clinical focus of the book and your insight into national disaster preparedness and re-provided valuable new clinical resource information for sponse initiatives.nurses. I am so fortunate to call the University of Rochester Welcome and thanks go to Amy T. Campbell, JD, School of Nursing my academic home. This phenom-MBE (University of Rochester, Division of Medical Hu- enal school is a leader in excellence in nursing edu-manities) for her detailed legal review and update of the cation and in entrepreneurship for nurses, and I havechapter on Legal and Ethical Issues in Disaster Response learned something from every one of my talented col-and to Joy Spellman (Burlington County College, New leagues. I wish to once again thank Dean Patricia Chiver-Jersey) for her contributions on preparing and promot- ton for creating an environment that supports new anding the role of the public health nurses during disasters. visionary initiatives and for supporting and encourag-Both of these authors were so gracious and generous ing me to do the work that I want to do. I am eternallywith their expertise. Thank you. grateful to Pat and to each of my fellow faculty mem- A very special warm welcome and thanks go to bers in the Leadership in Health Care Systems Master’sElizabeth A. Davis, JD, Ed.M and her colleagues Alan Program.Clive, PhD, Jane A. Kushma, PhD, and Jennifer Mincin, As I finish the second edition of this book, I wouldMPA. Elizabeth is the Founder and President of Eliza- also like to acknowledge 19 wonderfully talented in-beth Ann Davis Associates (http://www.eadassociates. dividuals and very special, terrific friends—my col-com/) and is a nationally recognized expert/advocate leagues in the 2004 Robert Wood Johnson Execu-for vulnerable populations. It was extremely important tive Nurse Fellowship: Carla Baumann, Suzanne Boyle,to me to add a substantive piece on planning for and Kathleen Capitulo, June Chan, Theresa Daggi, Kathrynresponding to the needs of high-risk, high-vulnerability Fiandt, Margaret Frankhauser, Mary Hooshmand, Paulpopulations in this edition of the book, and Alan, Eliz- Kuehnert, Mary Joan Ladden, Joan Marren, Marciaabeth, Jane, and Jennifer provided a superb chapter on Maurer, Marcella McKay, Wanda Montalvo, Kathleenthis topic (and in a relatively short time frame). My sin- Murphy, Cheri Rinehart, Mary Lou de Leon Siantz,cere thanks and admiration go out to each of you for Kristen Swanson, and Bonnie Westra. We have sharedyour work. an amazing experience in this wonderful program, and Welcome and gratitude go to Manish Shah, MD, they have provided me with insight and guidance forMPH, FACEP; Jeremy Cushman, MD, MS; Charles Mad- my work, of which this book represents a portion of thedow, MD, FACEP; and Jonnathan Busko, MD, MPH, overall project—ReadyRN: Making Every Nurse a Pre-EMT-P (University of Rochester, Department of Emer- pared Nurse. Their incredible work inspired me. Butgency Medicine), and to my colleague John Benitez, mostly I am grateful for the fun, friendship, and sup-MD, MPH at the Center for Disaster Medicine and port they offered. They believed in my vision for disaster
  • Acknowledgments ixnursing and for this book, and they are always there for I will be eternally grateful to my colleague and re-me when I need them. Thank you. search assistant Adam B. Rains for his assistance with Special thanks to Loretta Ford, former Dean and Pro- the preparation of this very large manuscript. Adam’s in-fessor Emeritus at the University of Rochester School of telligence, humor and wit—and limitless talent—were aNursing, and founder of the nurse practitioner role. I gift to this project.have had the amazing good fortune of having Lee as my Many thanks go to three very special women whomentor in the Robert Wood Johnson Executive Nurse are the best friends anyone could ask for—KatherineFellowship Program. There are no words to describe Lostumbo, Barbara Wale, and Maryanne Townsend. Thethis feisty, energetic, phenomenally talented nurse and warmth of your friendship continues to sustain me.scholar. She is a role model to the entire profession of Finally, the people to whom I owe the most are mynursing, and my life is richer for having known her. family. To my mother, thank you for all you have doneHer wisdom and guidance have played a pivotal role in for me and for thinking that I am much more capablemuch of my work the past few years. Her kindness and than I really am. You often told me, “to thine own selfsupport have sustained me. Thank you so much Lee. be true,” when making my life’s decisions—great advice I wish to thank all of my reviewers and those who that I have often passed down to my children. Thanksprovided valued commentary and recommendations. to my dad—I love you lots.Special thanks to Lori Barrette (University of Rochester), To my four children, I sincerely thank you for theJanice Springer (American Red Cross), and Lou Romig, joy you have brought to my life. You are my greatestMD, FAAP, FACEP. Just as there is no perfect research accomplishment. My sons Kyle, Blair, and Ryne—I lovestudy, there is also not a perfect textbook or reference you so much. A huge and especially special thank youmanual. This fact, however, did not dissuade us from goes to my wonderful daughter Kendall, who has beenseeking to make this book and every section in it the a terrific help to me for many, many years. Her wordsvery best it could be. Many thanks to all who shared of encouragement (and the sound of her laughter) havetheir wisdom and expertise during the preparation of always kept me going! She is my very best friend andthe book. the most incredible person I know. I would like to acknowledge Sally Barhydt and her And to my husband and partner in all life’s adven-colleagues at Springer Publishing Company in New York tures, my deepest thanks. I could not have done any ofCity. I sincerely thank you, Sally, for all your hard work this without you. You have helped me in too many waysin assisting with the publication of the second edition, to mention, and I am so appreciative of each and everyand for your ongoing commitment to me as an author. moment we have shared. Thank you.
  • ContributorsGary Ackerman, MA Sharon Benware, RN, CSPIDirector RA Lawrence Poison and Drug Information CenterCenter for Terrorism and Intelligence Studies Rochester, New YorkA Division of the Akribis GroupSan Jose, California Lisa Marie Bernardo, RN, PhD, MPH Associate ProfessorJanice B. Griffin Agazio, PhD, CRNP, RN University of Pittsburgh School of NursingAssistant Professor Pittsburgh, PennsylvaniaThe Catholic University of AmericaSchool of Nursing Jonnathan Busko, MD, MPH, EMT-PWashington, DC Emergency Physician / Medical Director, OperationsSherri-Lynne Almeida, DrPH, MSN, Med, RN, CEN Eastern Maine Medical CenterChief Operating Officer—Team Health Southwest Bangor, MaineHouston, Texas Regional Medical Director, Maine EMS Region 4Knox Andress, RN, FAEN Medical Director, Maine Medical Strike TeamDesignated Regional Coordinator New England MMRSLouisiana Region 7 Hospital Preparedness Medical Director, Northeastern Maine RegionalDirector of Emergency Preparedness Resource Center andLouisiana Poison Center Center for Emergency PreparednessShreveport, Louisiana Eastern Maine Healthcare SystemRandal D. Beaton, PhD, EMT Jennifer A. Byrnes, MLS, MPHResearch Professor University of Rochester School of MedicineDepartment of Psychosocial and Community and DentistryHealth Rochester, New YorkSchool of NursingAdjunct Research ProfessorDepartment of Health Services Amy T. Campbell, JD, MBESchool of Public Health and Community Medicine Division of Medical HumanitiesUniversity of Washington University of Rochester Medical CenterSeattle, Washington Rochester, New YorkJohn G. Benitez, MD, MPH Alan Clive, PhDAssociate Professor of Emergency Medicine, Emergency Management ConsultantEnvironmental Medicine and Pediatrics Silver Spring, MarylandUniversity of Rochester School of Medicine andDentistry Eric Croddy, MADirector, Finger Lakes Regional Resource Center Senior Research AssociateManaging and Associate Medical Director Monterey Institute of International StudiesRA Lawrence Poison and Drug Information Center Center for Nonproliferation StudiesRochester, New York Monterey, California xi
  • xii ContributorsJeremy T. Cushman, MD, MS P. Andrew Karam, PhD, CHPDivision of EMS and Office of Prehospital Senior Health PhysicistCare MJW CorporationDepartment of Emergency Medicine Rochester, New YorkUniversity of Rochester School of Medicine andDentistry Ziad N. Kazzi, MD, FAAEMRochester, New York Assistant Professor Medical ToxicologistKevin Davies, RRC, RN, MA, RNT, PGCE Department of Emergency MedicineSenior Lecturer in Nursing University of AlabamaSchool of Care Sciences Birmingham, AlabamaUniversity of GlamorganPontypridd, South Wales, United Kingdom Kerry Kehoe, MS Administrator, Division of Trauma, Burn &Elizabeth A. Davis, JD, Ed.M Emergency SurgeryDirector University of Rochester Medical CenterEAD & Associates, LLC Rochester, New YorkEmergency Management & Special Needs ConsultantsNew York, New York Paul Kuehnert, MS, RN Deputy DirectorPat Deeny, RN, RNT, BSc (Hons) Nursing Kane County Department of HealthAd Dip Ed. Aurora, IllinoisSenior Lecturer in NursingUniversity of Ulster, Magee Campus Jane A. Kushma, PhDDerry-Londonderry, Northern Ireland Associate Professor Institute for Emergency PreparednessMary Kate Dilts Skaggs, RN, MSN Jacksonville State UniversityDirector of Nursing Emergency Services Jacksonville, AlabamaSouthern Ohio Medical CenterPortsmouth, Ohio Linda Young Landesman, DrPH, MSW, ACSW, LCSW, BCDKristine M. Gebbie, DrPH, RN, FAAN NYC Health and Hospitals CorporationElizabeth Standish Gill Associate Professor New York, New YorkColumbia University School of NursingCenter for Health Policy Roberta Proffitt Lavin, MSN, APRN, BCNew York, New York CAPT, United States Public Health Service Director, Office of Human Services EmergencyMark Gillespie, RN, MSc Preparedness and ResponseAdvanced Nursing, Critical Nurse Specialist Administration for Children and FamiliesLecturer Trauma Nursing Department of Health and Human ServicesUniversity of Ulster, Magee Washington, DCDerry-Londonberry, Northern Ireland Christopher W. Lentz, MD, FACS, FCCMKevin D. Hart, JD, PhD Medical Director, Strong Regional Burn CenterAssistant Professor Associate Professor of Surgery andDepartment of Community and Preventative PediatricsMedicine University of Rochester School of Medicine andUniversity of Rochester School of Medicine Dentistryand Dentistry Rochester, New YorkRochester, New York Charles L. Maddow, MD, FACEPAngela J. Hodge, RN, BSN, CEN Department of Emergency MedicineClinical Coordinator for Emergency Services University of Rochester School of Medicine andSouthern Ohio Medical Center DentistryPortsmouth, Ohio Rochester, New York
  • Contributors xiiiNancy McKelvey, MSN, RN Kristine Qureshi, RN, CEN, DNScChief Nurse/Healthcare Partnerships Lead Associate ProfessorAmerican Red Cross School of Nursing and Dental HygieneWashington, DC University of Hawaii at Manoa Honolulu, HawaiiJennifer Mincin, MPASenior Project Manager Irwin Redlener, MDEAD & Associates, LLC Associate Dean & DirectorEmergency Management & Special Needs Consultants The National Center for Disaster PreparednessNew York, New York Columbia University Mailman School of Public Health New York, New YorkBrigitte L. Nacos, PhDDepartment of Political Science Dixie Reid, PAColumbia University Physician AssistantNew York, New York Trauma/Burn/Emergency Surgery University of Rochester School of Medicine andKaren Nason DentistryExecutive Director Rochester, New YorkAssociation of Rehabilitation NursesRehabilitation Nursing Certification Board Brooke Rera, MS, RN Burn Program ManagerSally A. Norton, PhD, RN University of Rochester/Strong Memorial HospitalAssistant Professor of Nursing Rochester, New YorkUniversity of Rochester School of Nursing Lt. Col. Richard Ricciardi, RN, FNPRochester, New York Uniformed Services University of the Health Sciences Graduate School of NursingCathy Peters, MS, RN, APRN-BC Bethesda, MarylandAssistant Clinical ProfessorUniversity of Rochester School of Nursing Lou E. Romig, MD, FAAP, FACEPAssistant Clinical Professor, Adjunct Faculty Pediatric Emergency MedicineDivision of Medical Humanities Miami Children’s HospitalUniversity of Rochester School of Pediatric Medical Advisor, Miami-Dade Fire RescueMedicine DepartmentRochester, New York South Florida Regional Disaster Medical Assistance Team (FL-5 DMAT)David C. Pigott, MD, FACEP Miami, FloridaResidency Program DirectorAssociate Professor and Vice Chair for Education Tara Sacco, MS, BS, RNDepartment of Emergency Medicine Burn Trauma UnitUniversity of Alabama at Birmingham University of Rochester Medical CenterBirmingham, Alabama Rochester, New YorkKathleen Coyne Plum, PhD, RN, NPP Manish N. Shah, MD, MPH, FACEPDirector, Office of Mental Health, Director, EMS ResearchMonroe County Department of Human Services Assistant ProfessorRochester, New York Department of Emergency MedicineAdjunct Associate Professor, University of Rochester Department of Community and Preventive MedicineSchool of Nursing University of Rochester School of Medicine andRochester, New York Dentistry Rochester, New YorkErica Rihl Pryor, RN, MSN, PhDDoctoral Program Coordinator and Assistant Professor Capt. Lynn A. Slepski, RN, MSN, PhD-C, CCNSUniversity of Alabama School of Nursing Senior Public Health AdvisorUniversity of Alabama at Birmingham Department of Homeland SecurityBirmingham, Alabama Washington, DC
  • xiv ContributorsJoy Spellman, MS, RN Jennifer TimonyDirector, Center for Public Health Preparedness PresidentBurlington County College National Student Nurses’ Association, Inc.Mt. Laurel, New Jersey Kathryn McCabe Votava, PhD, RN PresidentWendy Spencer GoodCare.comUniversity of Ulster Washington, DCJanice Springer, RN, PHN, MA Patricia Hinton Walker, PhD, RN, FAANDisaster Health Services Vice President for Nursing Policy and ProfessorAmerican Red Cross Uniformed Services University of theWashington, DC Health Sciences Bethesda, MarylandJoan M. Stanley, PhD, RN, CRNPDirector of Education Policy Dianne YeaterAmerican Association of Colleges of Director for Disaster Health ServicesNursing American Red CrossWashington, DC Washington, DC
  • DedicationOur world is not safe. Fraught with peril, it continuesto be a dangerous place in which to live. And yet weknow that our children need safe homes, safe schools,and safe communities to live in if they are to grow tobe healthy, happy, and secure adults. They are countingon us to be there for them—no matter what the cir-cumstances. They are counting on us to provide love,protection, and a safe harbor in the storm. They arecounting on us to be prepared. They are counting on usto rescue them when they need rescuing. This textbookis dedicated to our nation’s children—four in particular.To Kyle, Kendall, Blair, and Ryne—you are everything tome. Always know how much I love you and that homeis a safe harbor. And know that I tried to make the worlda safer place. xv
  • ForewordMost doctors, nurses, and other health workers look for- or man-made. It is increasingly appreciated that theward to a life pursuing their chosen career in relative phenomenon goes far beyond the punctual provisionorder, peace, and tranquility. However, the unexpected, of relief to the population affected and extends fromby its very nature, can strike anywhere, at any time, and advanced preparedness to the problems of long-terminvolve anybody or everybody, including those who are rehabilitation. While always emphasizing the use ofunprepared. A disaster can happen in any community proven management methods and practices, Dr. Veen-at any time. It is an inescapable fact brought into focus ema challenges nursing health professionals with ques-by the calamitous events we have seen befall our fellow tions that must still be answered in order for them tocitizens in just the past 5 years. From the four hurri- respond effectively in emergency situations. I know thatcanes that hit our coastal regions in just one 6-week decision makers at the highest echelons of governmentperiod in 2004 to the twin shocks of the South Asia have increasingly relied on the nursing profession totsunami and Hurricane Katrina; earthquakes in Indone- address the myriad problems facing a disaster-affectedsia; floods; terrorist bombings in the London subway community.and Iraq (an everyday phenomenon in Baghdad); and In the relatively short period of time that has elapseda humanitarian crisis of unimaginable horror in Sudan, since September 11, 2001, it is remarkable that a consid-it is clear that no community is immune. Nurses have erable body of new knowledge and experience relateda primary role in preparing for and managing medical to the adverse health effects of disasters has already ac-care during these episodic, but catastrophic, events. On cumulated. In fact, disaster research has accelerated toa global scale, nurses are active participants in caring such an extent that we probably need to update the re-for victims of a wide variety of disasters that take place sults of this research at a minimum of every year so thaton an almost daily basis. we can apply the lessons learned during one disaster to The second edition of Disaster Nursing and Emer- the management of the next. Conveying so much infor-gency Preparedness for Chemical, Biological, and Radio- mation in so few pages, with the right mix of scientificlogical Terrorism and Other Hazards has been designed data and human concern, in a practical and clear for-to provide emergency caregivers with a concise refer- mat, is no mean task. As the most comprehensive text-ence for managing specific disaster-preparedness and book on disaster nursing ever published (except for theresponse issues while providing the prerequisite back- groundbreaking first edition published in 2003), Disas-ground necessary to begin an in-depth study of the ter Nursing and Emergency Preparedness for Chemical,health consequences of the most common types of dis- Biological, and Radiological Terrorism and Other Haz-asters. The experience of the editor and many of the ards does exactly that and more. With years of experi-chapter authors is unique. The organizations for which ence, Dr. Veenema and co-authors give the reader amplethey work cover the range of disasters that strike this technical descriptions of each kind of disaster (partic-world. We owe an enormous debt of gratitude to them ularly chemical, biological, radiological terrorism, andall for their unstinting efforts to update this classic work. other hazards), an examination of the kinds of issues Postdisaster evaluations conducted by nurses of the and problems that arise in planning hospital and emer-management of disasters by health professionals have gency department disaster response, and an up-to-dateprovided critical data for mitigating the human impact review of the more common medical and managementof these events and enhancing future responses to disas- issues that might face a nurse involved in a local disas-ters. This has been especially true regarding Hurricane ter. Unique chapters include those addressing the legalKatrina. As a result, disaster management is well rec- and ethical issues in disaster response, the role of theognized as far more than just triage and mass casu- media, effective communication with the public (a ma-alty management. Since the first edition of this book jor deficiency during Hurricane Katrina and the Southwas published, we have seen significant changes in Asia tsunami), the special needs of children during dis-the health management of disasters, whether natural asters and public health emergencies, and the evolving xvii
  • xviii Forewordpriorities of the Departments of Health and Human Ser- on which to base their activities. This highly topicalvices and Homeland Security. book will serve as the most up-to-date course textbook Like the first edition, the second edition includes and desk reference available not only for nursing pro-well-designed case studies that provide realistic, hands- fessionals responsible for preparing their hospitals foron experiences that challenge the reader to apply infor- responding to disasters and other public health emer-mation provided in the chapters. Dr. Veenema’s inclu- gencies but also for emergency managers and other de-sion of “Key Messages” and “Learning Objectives” that cision makers charged with ensuring that disasters areintroduce each major section of the book, plus unique well managed.case studies addressing natural, industrial, and terror-ism disasters, has resulted in the creation of a major re- Eric K. Noji, MD, MPH, FACEPsource that will serve as a timely, comprehensive, and Program Directorstructured text for the education of hospital, community, Pandemic Avian Influenza Preparednessstate, and national health and medical emergency man- Programagers, as well as nursing students who will assume ma-jor mass emergency preparedness responsibilities im- Global Epidemic Intelligence Networkmediately after graduation. Center for Disaster Medicine & Humanitarian It is incumbent that all health care workers, and Assistancenurses in particular, react professionally, efficiently, ra- Department of Military & Emergency Medicinetionally, and effectively when disaster strikes. To do so, Uniformed Services University of thethey need some fundamental principles and knowledge Health Sciences Bethesda, Maryland
  • ForewordIn the years since the first edition of this book was pub- knew that disaster nursing had virtually disappearedlished, the complexity of terrorism has continued to in- from our curricula, although we still incorporated basiccrease. We now are very aware that terrorists exist, not population-based public health principles. If one goodonly outside our country trying to get in, but also inside thing comes out of the tragedy of 9/11, it will be thatour country in small towns and large cities where some monies granted from Congress to address terrorism willof our own citizens are plotting our downfall. serve a dual role and also help strengthen our public I have always said that nurses are the glue that holds health infrastructure.our health care delivery system (as fragmented as it is) The book you are about to read offers a comprehen-together. Once a nurse, always a nurse! Nurses in our sive analysis of a broad range of disasters possible in to-communities are also expected to be able to respond to day’s world—both those wreaked by humans as well asthe natural and man-made disasters that we will surely by nature. This text is the next generation of informationencounter in the next few years. Our response must be needed by nurses to be informed about and responsiveevidence based, as is so well exemplified by these chap- to the needs of our citizens in a disaster. Katrina was aters. This text gathers together the best thoughts about wake-up event. The roles that nurses and nurse assis-evidence-based response wherever possible and identi- tants played in that disaster were selfless and inspiring.fies where the evidence is spotty and slim. Katrina only served to undergird our awareness that we As the founder of the International Nursing Coali- must be vigilant and prepared!tion for Mass Casualty Education in March 2001(now the Nursing Emergency Preparedness EducationCoalition), which now represents over 80 nursing orga- Colleen Conway-Welch, PhD, RN, CNM, FAAN,nizations, friends of nursing, and subject matter experts, FACNMI was not privy to any special vision. I knew that ourpublic health infrastructure was rickety—at best—and Nancy & Hilliard Travis Professor of Nursingthat, in the event of any kind of mass casualty event, Deannurses would be expected to be in the forefront. I also Vanderbilt University School of Nursing xix
  • Special ForewordAs a Robert Wood Johnson Executive Nurse Fellow, Dr. expanded scope ranges from preparedness and man-Veenema, a disaster nursing expert, chose to pursue agement to specific types of disasters, ending witha lofty fellowship goal of “creating a national nursing chapters on nursing education, research, and globalworkforce adequately prepared to respond to a disaster connections.or any major public health emergency.” This monumen- I would find this edition particularly useful for itstal undertaking sounds and is formidable. Still, this sec- teaching/learning framework that focuses the learnerond edition of her highly successful earlier publication, on goals and expected outcomes. Case studies expediteDisaster Nursing, convinces me she is well on the way discourse and critical thinking as do references and In-toward that goal. ternet sources. This expanded and updated edition is all encom- In its expanded form and extensive content, this sec-passing and forms the basis for all her other efforts ond edition is indeed required reading as a textbook, ain developing printware and software and educational reference, a compendium of comprehensive topics, andforums, coordinating and collaborating with volunteer foundational to “making every nurse a prepared nurse.”and governmental agencies, and encouraging educa-tional and professional organizations to help prepare Loretta C. Ford, RN, PNP, EdDnurses and other health professionals for natural and Dean Emeritusman-made disasters. The breadth and depth of this pub- University of Rochester School of Nursinglication are phenomenally comprehensive and practi- Founder of the Nurse Practioner Programcal as well as theoretically and scientifically sound. Itsxx
  • Contents About the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Foreword (Eric K. Noji ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Foreword (Colleen Conway-Welch) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Special Foreword (Loretta C. Ford ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx P A R T I DISASTER PREPAREDNESSChapter 1 Essentials of Disaster Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Tener Goodwin VeenemaChapter 2 Leadership and Coordination in Disaster Health Care Systems: The Federal Disaster Response Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Roberta Lavin, Lynn Slepski, and Tener Goodwin VeenemaChapter 3 Emergency Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Jeremy T. Cushman, Manish N. Shah, Charles L. Maddow, and Jonnathan BuskoChapter 4 American Red Cross Disaster Health Services and Disaster Nursing . . . . . . . . . . . . . . . 67 Dianne Yeater and Nancy McKelveyChapter 5 Understanding the Psychosocial Impact of Disasters . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Kathleen Coyne PlumChapter 6 Legal and Ethical Issues in Disaster Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Amy T. Campbell, Kevin D. Hart, and Sally A. NortonChapter 7 Crisis Communication: The Role of the Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Brigitte L. Nacos xxi
  • xxii Contents P A R T I I DISASTER MANAGEMENTChapter 8 Disaster Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Kristine Qureshi and Kristine M. GebbieChapter 9 Disaster Triage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Kristine Qureshi and Tener Goodwin VeenemaChapter 10 Restoring Public Health Under Disaster Conditions: Basic Sanitation, Water and Food Supply, and Shelter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Tener Goodwin VeenemaChapter 11 Managing Emergencies Outside of the Hospital: Special Events, Mass Gatherings, and Mass Casualty Incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Tener Goodwin VeenemaChapter 12 Management of Burn Mass Casualty Incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Christopher Lentz, Dixie Reid, Brooke Rera, and Kerry KehoeChapter 13 Traumatic Injury Due to Explosives and Blast Effects . . . . . . . . . . . . . . . . . . . . . . . . . 239 Tara SaccoChapter 14 Management of Psychosocial Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Kathleen Coyne Plum and Tener Goodwin VeenemaChapter 15 Unique Needs of Children During Disasters and Other Public Health Emergencies . . . . 273 Lisa Marie BernardoChapter 16 Identifying and Accommodating High-Risk and High-Vulnerability Populations . . . . . . . 309 Alan Clive, Elizabeth A. Davis, Jane A. Kushma, and Jennifer Mincin P A R T I I I NATURAL AND ENVIRONMENTAL DISASTERSChapter 17 Natural Disasters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 Linda Young Landesman and Tener Goodwin VeenemaChapter 18 Environmental Disasters and Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 Tener Goodwin Veenema
  • Contents xxiii P A R T I V DISASTERS CAUSED BY CHEMICAL, BIOLOGICAL, AND RADIOLOGICAL AGENTSChapter 19 Biological and Chemical Terrorism: A Unique Threat . . . . . . . . . . . . . . . . . . . . . . . . . . 365 Eric Croddy and Gary AckermanChapter 20 Surveillance Systems for Detection of Biological Events . . . . . . . . . . . . . . . . . . . . . . . 389 Erica Rihl PryorChapter 21 Biological Agents of Concern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403 David C. Pigott and Ziad N. KazziChapter 22 Early Recognition and Detection of Biological Events . . . . . . . . . . . . . . . . . . . . . . . . . 423 Erica Rihl PryorChapter 23 Emerging Infectious Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437 Jennifer A. ByrnesChapter 24 Design and Implementation of Mass Immunization and Prophylactic Treatment Clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459 Kathryn McCabe VotavaChapter 25 Chemical Agents of Concern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483 Tener Goodwin Veenema, John Benitez, and Sharon BenwareChapter 26 Mass Casualty Decontamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505 Tener Goodwin VeenemaChapter 27 Radiological Incidents and Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521 Andrew Karam P A R T V SPECIAL TOPICSChapter 28 Directions for Nursing Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545 Joan M. Stanley and Tener Goodwin VeenemaChapter 29 Directions for Nursing Research and Development . . . . . . . . . . . . . . . . . . . . . . . . . . . 559 Richard Ricciardi, Janice B. Griffin Agazio, Roberta P. Lavin, and Patricia Hinton Walker
  • xxiv ContentsChapter 30 Global Issues in Disaster Relief Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571 Pat Deeny, Kevin Davies, Mark Gillespie, and Wendy SpencerChapter 31 The Role and Preparation of the Public Health Nurse for Disaster Response . . . . . . . . . 589 Joy SpellmanEpilogue Disaster Recovery: Creating Sustainable Disaster-Resistant Communities . . . . . . . . . . 601 Tener Goodwin VeenemaAppendices I Internet Resources on Disaster Preparedness, Emergency Care, and Bioterrorism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603 II Glossary of Terms Commonly Used in Disaster Preparedness and Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607 III Bioterrorism and Emergency Readiness: Competencies for All Public Health Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615 IV Federal Emergency Management Agency: Emergency Response Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617 V Anthrax Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620 VI Botulism Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621 VII Plague Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622 VIII Smallpox Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623 IX Tularemia Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624 X Viral Hemorrhagic Fevers Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625 XI Biological Weapon (BW) Agent Lab Identification . . . . . . . . . . . . . . . . . . . . . . 626 XII Patient Isolation Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630 XIII Creating a Personal Disaster Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 632INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637
  • P A R T IDisasterPreparedness
  • Key Messages ■ The frequency of natural disasters, the individuals affected by them, and the eco- nomic costs associated with loss have been steadily increasing over recent years. ■ While disasters are often unexpected, sound disaster planning can anticipate common problems and mitigate the consequences of the event. ■ Different types of disasters are associated with distinct patterns of illness and injury, and early assessment of risks and vulnerability can reduce morbidity and mortality later on. ■ Effective disaster plans are based on knowledge of how people behave. Key com- ponents and common tasks must be included in any disaster preparedness plan. ■ The actual process of planning is more important than the resultant written plan because those who participate in planning are more likely to accept preparedness plans in general. ■ Disaster planning must overcome apathy and complacency. ■ Disasters are different from daily emergencies; most cannot be managed simply by mobilizing additional personnel and supplies. Certain commonly occurring problems can be anticipated and addressed during planning. ■ A professional mandate exists that calls for nurses to participate in the develop- ment of and serve as an integral part of a community’s disaster preparedness plan. ■ Nurses must participate as full partners with both the medical community and emergency management community in all aspects of disaster response and recovery.Learning Objectives When this chapter is completed, readers will be able to 1. Classify the major types of disasters based on their unique characteristics and describe their consequences. 2. Identify societal factors that have contributed to increased losses (human and property) as the result of disasters. 3. Describe two principles of disaster planning, including the agent-specific and the all-hazards approach, and the basic components of a disaster plan. 4. Discuss the five areas of focus in emergency and disaster planning: prepared- ness, mitigation, response, recovery, and evaluation. 5. Describe risk assessment, hazard identification, and vulnerability analysis. 6. Assess constraints on a community’s or organization’s ability to respond. 7. Describe the core preparedness actions. 8. Recognize situations suggestive of an increased need for additional comprehen- sive planning.
  • Essentials of Disaster 1 Planning Tener Goodwin Veenema C H A P T E R O V E R V I E W The principles of disaster planning, the common tasks emergency and disaster preparedness—preparedness, consistent across all disaster responses, and the key mitigation, response, recovery, and evaluation—are components of a disaster preparedness plan are addressed. Risk assessment, hazard identification and introduced in this chapter. Definitions of the different types mapping, and vulnerability analysis are presented as of disasters are provided, along with a classification methods for decision making and planning. The concepts system for disasters based on their common and unique of disaster epidemiology and measurement of the features; onset, duration, and effect (immediate magnitude of a disaster’s impact on population health are aftermath); and reactive period. The concept of the explored. Situations suggestive of an increased need for disaster time line as an organizational framework for planning, such as bioterrorism and hazmat (hazardous strategic planning is introduced. The five areas of focus in material) events, are addressed. nomic losses associated with these events have placedINTRODUCTION an imperative on disaster planning for emergency pre- paredness. Global warming, shifts in climates, sea-levelDisasters have been integral parts of the human expe- rise, and societal factors may coalesce to create futurerience since the beginning of time, causing premature calamities. Finally, war, acts of aggression, and the inci-death, impaired quality of life, and altered health sta- dence of terrorist attacks are reminder of the potentiallytus. The risk of a disaster is ubiquitous. On average, one deadly consequences of man’s inhumanity toward man.disaster per week that requires international assistance A review of recent disasters since 2000—politicaloccurs somewhere in the world. The recent dramatic in- strife and conflicts in Angola, Afghanistan, Ethiopia,crease in natural disasters, their intensity, the number D.R. Congo, Sudan, Iraq, and Sierra Leone—indicatesof people affected by them, and the human and eco- that few disasters are the result of a single cause and
  • 4 Part I Disaster Preparednesseffect. The disasters unfolding in this century are fre- (p. 1). Disasters may be classified into two broad cate-quently complex human emergencies associated with gories: natural (those caused by natural or environmen-global instability, economic decay, political upheaval tal forces) or man-made (human generated). The Worldand collapse of government structures, violence and Health Organization defines natural disaster as the “re-civil conflicts, famine, and mass population displace- sult of an ecological disruption or threat that exceedsments. The Sumatra tsunami and Hurricane Katrina, the adjustment capacity of the affected community”as well as the 2004 and 2006 hurricane seasons, point (Lechat, 1979). Natural disasters include earthquakes,to more natural disasters and their growing complex- floods, tornadoes, hurricanes, volcanic eruptions, iceity, which create considerable challenges to disaster storms, tsunamis, and other geologic or meteorologi-planners. cal phenomena. Man-made disasters are those in which In the United States, nurses constitute the largest the principal direct causes are identifiable human ac-sector of the health care workforce and will certainly be tions, deliberate or otherwise (Noji, 1996). Man-madeon the front lines of any emergency response. As part of disasters include biological and biochemical terrorism,the country’s overall plan for disaster preparedness, all chemical spills, radiological (nuclear) events, fire, ex-nurses must have a basic understanding of disaster sci- plosions, transportation accidents, armed conflicts, andence and the key components of disaster preparedness, acts of war.including the following: Human-generated disasters can be further divided into three broad categories: (a) complex emergencies,(1) The definition and classification system for disasters (b) technologic disasters, and (c) disasters that are not and major incidents based on common and unique caused by natural hazards but occur in human settle- features of disasters (onset, duration, effect, and re- ments. Complex emergencies involve situations where active period). populations suffer significant casualties as a result of(2) Disaster epidemiology and measurement of the war, civil strife, or other political conflict. Some disasters health consequences of a disaster. are the result of a combination of forces such as drought,(3) The five areas of focus in emergency and disaster famine, disease, and political unrest that displace mil- preparedness: preparedness, mitigation, response, lions of people from their homes. These humanitarian recovery, and evaluation. disasters can be epic in proportion, such as civilians flee-(4) Methods such as risk assessment, hazard identifica- ing the Iraq war or refugees displaced by the conflict in tion and mapping, and vulnerability analysis. Darfur. With technologic disasters, large numbers of peo-(5) Awareness of the role of the nurse in a much larger ple, property, community infrastructure, and economic response system. welfare are directly and adversely affected by major in- dustrial accidents; unplanned release of nuclear energy; This chapter introduces the reader to the princi- and fires or explosions from hazardous substances suchples of disaster planning, the common tasks consistent as fuel, chemicals, or nuclear materials (Noji, 1996).across all disaster responses, and the key components The distinction between natural and human-generatedof a disaster preparedness plan. disasters may be blurred; a natural disaster, or phe- nomenon, may trigger a secondary disaster, the result of weaknesses in the human environment. An exampleDEFINITION AND CLASSIFICATION of this is a chemical plant explosion following an earth-OF DISASTERS quake. Such combinations, or synergistic disasters, are commonly referred to as NA-TECHs (Natural and Tech-Disasters have many definitions. Disaster may be de- nological Disasters) (Noji, 1996). A NA-TECH disasterfined as any destructive event that disrupts the nor- occurred in the former Soviet Union, when windstormsmal functioning of a community. Disasters have been spread radioactive materials across the country, increas-defined as ecologic disruptions, or emergencies, of a ing by almost 50% the land area contaminated in an ear-severity and magnitude that result in deaths, injuries, lier nuclear disaster. Disasters can and do occur simul-illness, and property damage that cannot be effectively taneously (e.g., a chemical attack along with a nuclearmanaged using routine procedures or resources and that assault), potentiating the death and devastation createdrequire outside assistance (Landesman et al., 2001). by each.Health care providers characterize disasters by what Disasters are frequently categorized based on theirthey do to people—the consequences on health and onset, impact, and duration. For example, earthquakeshealth services. A medical disaster is a catastrophic and tornadoes are rapid-onset events—short durationsevent that results in causalities that overwhelm the but with a sudden impact on communities. Hurricaneshealth care resources in that community (Al-Madhari and volcanic eruptions have a sudden impact on a& Zeller, 1997). Noji (1997) describes disasters quite community; however, frequently advance warnings aresimply, as “events that require extraordinary efforts be- issued enabling planners to implement evacuation andyond those needed to respond to everyday emergencies” early response plans. A bioterrorism attack may be
  • Chapter 1 Essentials of Disaster Planning 5sudden and unanticipated and have a sudden and pro- in 1988 and amended in 2000, provides for federal gov-longed impact on a community. ernment assistance to state and local governments to In contrast, droughts and famines have a more grad- help them manage major disasters and emergencies.ual onset or chronic genesis (the so-called creeping dis- Under the Stafford Act, the president may provide fed-asters) and generally have a prolonged impact. Factors eral resources, medicine, food and other consumables,that influence the impact of a disaster on a commu- work assistance, and financial relief (Stafford Act). Onnity include the nature of the event, time of day or year, average, 38 presidential disaster declarations are madehealth and age characteristics of the population affected, per year; most are made immediately following im-and the availability of resources (Gans, 2001). Further pact, and review of recent years’ data suggests that theclassification of terms in the field of disaster science number of disasters is increasing (see Table 1.1; Fed-distinguishes between hazards and disasters. Hazards eral Emergency Management Agency [FEMA], 2007).present the possibility of the occurrence of a disaster If the consequences of a disaster are clear and im-caused by natural phenomena (e.g., hurricane, earth- minent and warrant redeployment actions to lessenquake), failure of man-made sources of energy (e.g.,nuclear power plant), or by human activity (e.g., war). Defining an event as a disaster also depends on thelocation in which it occurs, particularly the populationdensity of that location. For example, an earthquake oc-curring in a sparsely populated area would not be con- 1.1 Federally Declared Disasters 1976–2007sidered a disaster if no people were injured or affected YEAR TOTAL DISASTER DECLARATIONSby loss of housing or essential services. However, theoccurrence of even a small earthquake could produce 1976 30extensive loss of life and property in a densely pop- 1977 22ulated region (such as Los Angeles) or a region with 1978 25inadequate construction or limited medical resources. 1979 42Similarly, numbers and types of casualties that might 1980 23be handled routinely by a large university hospital or 1981 15metropolitan medical center could overwhelm a small 1982 24community hospital. 1983 21 Hospitals and other health care facilities may fur- 1984 34ther classify disasters as either “internal” or “external.” 1985 27External disasters are those that do not affect the hos- 1986 28pital infrastructure but do tax hospital resources due to 1987 23 1988 11numbers of patients or types of injuries (Gans, 2001). 1989 31For example, a tornado that produced numerous in- 1990 38juries and deaths in a community would be considered 1991 43an external disaster. Internal disasters cause disruption 1992 45of normal hospital function due to injuries or deaths 1993 32of hospital personnel or damage to the physical plant, 1994 36as with a hospital fire, power failure, or chemical spill 1995 32(Aghababian, Lewis, Gans, & Curley, 1994). Unfortu- 1996 75nately, one type of hospital disaster does not necessarily 1997 44preclude the other, and features of both internal and ex- 1998 65ternal disasters may be present if a natural phenomenon 1999 50 2000 45affects both the community and the hospital. This was 2001 45the case with Hurricane Andrew (1992), which caused 2002 49significant destruction in hospitals, in clinics, and in the 2003 56surrounding community when it struck south Florida 2004 68(Sabatino, 1992), and Hurricane Katrina (2005) when 2005 48it impacted the Gulf Coast, rupturing the levee in New 2006 52Orleans (Berggren, 2005). 2007 14 (as of March, 2007) Total 1,193 Average 38DECLARATION OF A DISASTER Source: Federal Emergency Management Agency (2007). RetrievedIn the United States, the Robert T. Stafford Disaster Re- 3/07/07 from http://www.fema.gov/news/disaster totals annual.femalief and Emergency Assistance Act, passed by Congress
  • 6 Part I Disaster Preparedness Figure 1.1 Billion dollar U.S. weather disasters, 1980–2004—National Oceanic and Atmo- spheric Administration. Source: Retrieved from the World Wide Web 5/10/06 at http://www.1.nedc.noaa.gov/pub/data/special/billion2004.pdfor avert the intensity of the threat, a state’s gover- the population may be rendered homeless and forced tonor may request assistance even before the disaster relocate temporarily or permanently. Disasters damagehas occurred. A library of all past and current feder- and destroy businesses and industry, agriculture, andally declared disasters in the United States can be lo- the economic foundation of the community. The im-cated at the FEMA Web site (http://www.fema.gov/ pact of weather disasters alone has generated costs oflibrary/dizandemer.shtm). A current list of international over a billion dollars (see Figure 1.1). The federal gov-declared disasters and emergencies and links to disease ernment committed $85 billion to recovery efforts foroutbreaks can be located on the World Health Organi- Hurricane Katrina alone. The health effects of disasterszation’s Web site (http://www.who.int/health topics/ may be extensive and broad in their distribution acrossdisasters/en/). populations (see chapter 8 for further discussion). In addition to causing illness and injury, disasters disrupt access to primary care and preventive services. Depend-HEALTH EFFECTS OF DISASTERS ing on the nature and location of the disaster, its effects on the short- and long-term health of a population mayDisasters affect communities and their populations in be difficult to measure.different ways. Damaged and collapsed buildings are ev- Epidemiology, as classically defined, is the quan-idence of physical destruction. Roads, bridges, tunnels, titative study of the distributions and determinants ofrail lines, telephone and cable lines, and other trans- health-related events in human populations (Gordis,portation and communication links are often destroyed. 2004; see chapter 15 for further discussion). DisasterPublic utilities (e.g., water, gas, electricity, and sewage epidemiology is the measurement of the adverse healthdisposal) may be disrupted. A substantial percentage of effects of natural and human-generated disasters and
  • Chapter 1 Essentials of Disaster Planning 7the factors that contribute to those effects, with the propensity for a disaster to occur. Warning (also knownoverall objective of assessing the needs of disaster- as forecasting) refers to monitoring events to look foraffected populations, matching available resources to indicators that predict the location, timing, and magni-needs, preventing further adverse health effects, eval- tude of future disasters.uating program effectiveness, and planning for con- Mitigation includes measures taken to reduce thetingencies (Lechat, 1990; Noji, 1996). Disasters affect harmful effects of a disaster by attempting to limit itsthe health status of a community in the following impact on human health, community function, and eco-ways: nomic infrastructure. These are all steps that are taken to lessen the impact of a disaster should one occur and■ Disasters may cause premature deaths, illnesses, and can be considered as prevention measures. Prevention injuries in the affected community, generally exceed- refers to a broad range of activities, such as attempts ing the capacity of the local health care system. to prevent a disaster from occurring, and any actions■ Disasters may destroy the local health care infrastruc- taken to prevent further disease, disability, or loss of ture, which will therefore be unable to respond to the life. Mitigation usually requires a significant amount of emergency. Disruption of routine health care services forethought, planning, and implementation of measures and prevention initiatives may lead to long-term con- before the incident occurs. sequences in health outcomes in terms of increased The response phase is the actual implementation of morbidity and mortality. the disaster plan. Disaster response, or emergency man-■ Disasters may create environmental imbalances, in- agement, is the organization of activities used to ad- creasing the risk of communicable diseases and envi- dress the event. Traditionally, the emergency manage- ronmental hazards. ment field has organized its activities in sectors, such as■ Disasters may affect the psychological, emotional, fire, police, hazardous materials management (hazmat), and social well-being of the population in the affected and emergency medical services. The response phase community. Depending on the specific nature of the focuses primarily on emergency relief: saving lives, pro- disaster, responses may range from fear, anxiety, and viding first aid, minimizing and restoring damaged sys- depression to widespread panic and terror. tems such as communications and transportation, and■ Disasters may cause shortages of food and cause se- providing care and basic life requirements to victims vere nutritional deficiencies. (food, water, and shelter). Disaster response plans are■ Disasters may cause large population movements most successful if they are clear and specific, simple to (refugees) creating a burden on other health care sys- understand, use an incident command system, are rou- tems and communities. Displaced populations and tinely practiced, and updated as needed. Response ac- their host communities are at increased risk for com- tivities need to be continually evaluated and adjusted to municable diseases and the health consequences of the changing situation. crowded living conditions. (Noji, 1996) Recovery actions focus on stabilizing and return- ing the community (or an organization) to normal (its preimpact status). This can range from rebuilding dam- aged buildings and repairing infrastructure, to relocatingTHE DISASTER CONTINUUM populations and instituting mental health interventions. Rehabilitation and reconstruction involve numerousThe life cycle of a disaster is generally referred to as the activities to counter the long-term effects of the disasterdisaster continuum, or emergency management cycle. on the community and future development.This life cycle is characterized by three major phases, Evaluation is the phase of disaster planning and re-preimpact (before), impact (during), and postimpact (af- sponse that often receives the least attention. After ater), and provide the foundation for the disaster time disaster, it is essential that evaluations be conducted toline (Figure 1.2). Specific actions taken during these determine what worked, what did not work, and whatthree phases, along with the nature and scope of the specific problems, issues, and challenges were identi-planning, will affect the extent of the illness, injury, and fied. Future disaster planning needs to be based on em-death that occurs. pirical evidence derived from previous disasters. The five basic phases of a disaster management pro-gram include preparedness, mitigation, response, recov-ery, and evaluation (Kim & Proctor, 2002; Landesman, DISASTER PLANNING2001). There is a degree of overlap across phases, buteach phase has distinct activities associated with it. Effective disaster planning addresses the problems Preparedness refers to the proactive planning efforts posed by various potential events, ranging in scale fromdesigned to structure the disaster response prior to its mass casualty incidents, such as motor vehicle collisionsoccurrence. Disaster planning encompasses evaluating with multiple victims, to extensive flooding or earth-potential vulnerabilities (assessment of risk) and the quake damage, to armed conflicts and acts of terrorism
  • 8 Part I Disaster Preparedness Figure 1.2 Disaster nursing timeline. Copyright Tener Goodwin Veenema, PhD, MPH, MS, CPNP(Gans, 2001). The disaster-planning continuum is broad the sanitation needs of crowds at mass gatherings, to thein scope and must address collaboration across agen- psychosocial needs of vulnerable populations, to evac-cies and organizations, advance preparations, as well uation procedures for buildings and geographic areas—as needs assessments, event management, and recovery when designing a detailed response (Leonard, 1991; Par-efforts. Although public attention frequently focuses on illo, 1995). Completion of the disaster planning processmedical casualties, it is imperative to consider numer- should result in the production of a comprehensive dis-ous other factors when disaster plans and responses are aster or “emergency operations plan.”being designed and developed. Participation by nursesin all phases of disaster planning is critical to ensurethat nurses are aware of and prepared to deal with what- TYPES OF DISASTER PLANNINGever these numerous other factors may turn out to be.Individuals and organizations responsible for disaster The two major types of disaster plans are those thatplans should consider all possible eventualities—from take the agent-specific approach and those that use the
  • Chapter 1 Essentials of Disaster Planning 9all-hazards approach. Communities that embrace theagent-specific approach focus their preparedness activ-ities on the most likely threats to occur based on theirgeographic location (e.g., hurricanes in Florida). Theall-hazards approach is a conceptual model for disas-ter preparedness that incorporates disaster managementcomponents that are consistent across all major typesof disaster events to maximize resources, expenditures,and planning efforts. It has been observed that despitetheir differences many disasters share similarities be-cause certain challenges and similar tasks occur re-peatedly and predictably. The Department of HomelandSecurity’s National Response Plan encourages all com-munities to prepare for disasters using the all-hazardsapproach instead of stand-alone plans, and the agency Figure 1.3 New York, NY, October 5, 2001—The clean-uppublished its guidelines for all-hazards preparedness ti- operation continues all through the week and weekend, withtled Guide for All-Hazards Emergency Operations Plan- thousands of tons having been removed already. Photo by Andrea Booher/FEMA News Photo. Source: FEMA, 2001ning (1996). These guidelines are helpful in developingcommunity emergency operations plans. Problems, issues, and challenges are commonly en- event of future disaster situations. Challenges to addresscountered across several types of disasters (Auf der proactively are discussed next.Heide, 1996, 2002; Landesman, 2001). Frequently, these Communication, sharing information among orga-issues and challenges can be effectively addressed in nizations and across many people, is a major prioritycore preparedness activities and include the following: in any disaster planning initiative. Failure of the com- munication system may occur in the event of a disas- ter, as a result of damage to the infrastructure caused 1. Communication problems. by the disaster, as well as lack of operator familiarity, 2. Triage, transportation, and evacuation problems. excessive demands, inadequate supplies, and lack of 3. Leadership issues. integration with other communications providers and 4. The management, security of, and distribution of technologies. Backup communications systems, such as resources at the disaster site. wireless, hardwire, and cellular telephones, may reduce 5. Advance warning systems and the effectiveness of the impact of disrupted standard communications, but, warning messages. frequently, even advanced technology has been ineffec- 6. Coordination of search and rescue efforts. tual during disasters (Garshnek & Burkle, 1999). Alter- 7. Media issues. native ways for the public, as well as health providers, 8. Effective triage of patients (prioritization for care to get accurate information is critically important. The and transport of patients). 9/11 World Trade Center disaster demonstrated the need 9. Distribution of patients to hospitals in an equitable for reliable communication systems such as two-way ra- fashion. dios and assured backup systems (see Figure 1.3).10. Patient identification and tracking. A detailed process for the efficient and effective dis-11. Damage or destruction of the health care infrastruc- tribution of all types of resources, including supplemen- ture. tal personnel, equipment, and supplies among multi-12. Management of volunteers, donations, and other ple organizations and the establishment of a security large numbers of resources. perimeter around a disaster site should also be in-13. Organized improvisational response to the disrup- cluded in the plan. Leadership responsibilities and co- tion of major systems. ordination of all rescue efforts (across territories and14. Finally, encountering overall resistance (apathy) to jurisdictions) should be worked out in advance of any planning efforts. Auf der Heide states, “Interest in event. disaster preparedness is proportional to the recency Advance warning systems and the use of evacua- and magnitude of the last disaster” (1989). tion from areas of danger save lives and should be in- cluded in community disaster response plans whenever appropriate. Warnings can now be made months in ad-CHALLENGES TO DISASTER PLANNING ˜ vance, in the case of El Nino, to seconds in advance of the arrival of earthquake waves at some distanceAdequate planning can address many of these issues from the earthquake. Computers are being programmedin advance and even eliminate some as problems in the to respond to warnings automatically, shutting down
  • 10 Part I Disaster Preparedness Figure 1.4 New Orleans, LA, September 9, 2005—Neighborhoods throughout the area re- main flooded as a result of Hurricane Katrina. Crews work on areas where there have been breaks in the levee in order to avoid additional flooding. Photo by Jocelyn Augustino. Source: FEMA, 2005or appropriately modifying transportation systems, life- transferred without adequate triage and that patientlines, and manufacturing processes. Warnings are be- distribution to existing health care facilities is oftencoming much more useful to society as lead time and grossly unequal and uncoordinated (Auf der Heide,reliability are improved and as society devises ways to 1996, 2002).respond effectively. Effective dissemination of warnings Disaster planning must include a community mu-provides a way to reduce disaster losses that have been tual aid plan in the event that the hospital(s), nursingincreasing in the United States as people move into at- home(s), or other residential health care facility needs torisk areas (FEMA, 2000). be evacuated. Plans for evacuation of health care facili- A plan for the use of the mass media for the purpose ties must be realistic and achievable, and contain suffi-of disseminating public health messages in the postim- cient specific detail as to where patients will be relocatedpact phase in order to avoid health problems (e.g., water to and who will be there to care for them. Patient evacu-safety, food contamination) should be developed in ad- ation was a major challenge to disaster response effortsvance. Nurses and other disaster responders may need following Hurricane Katrina, and was hampered by thetraining in how to interact effectively with the media. destruction of all major transportation routes in and out(See chapter 5 for further discussion.) of the city. Pre-planning for the possibility of the need A comprehensive disaster plan will account for the to evacuate entire health care facilities must address al-effective triage of patients (prioritization for care and ternative modes of transportation and include adequatetransport of patients) and distribution of patients to hos- security measures (see Figure 1.4).pitals (a coordinated, even distribution of patients to For large-scale disasters involving a broad geo-several hospitals as opposed to delivering most of the graphic region, disaster-medical aid-centers may needpatients to the closest hospital). Review of previous dis- to be established and evenly spaced throughout a com-aster response efforts reveals that patients are frequently munity. These disaster-medical aid-centers are provided
  • Chapter 1 Essentials of Disaster Planning 11 HAZARD IDENTIFICATION, VULNERABILITY ANALYSIS, AND RISK ASSESSMENT Hazard identification and mapping, vulnerability analy- sis, and risk assessment are the three cornerstone meth- ods of data collection for disaster planning (see Table 1.2). The first step in effective disaster planning requires advance identification of potential problems for the in- stitution or community involved (Gans, 2001). Different types of disasters are associated with distinct patterns of illness and injuries, and limited predictions of these health outcomes can sometimes be made in advance, with appropriate and adequate data. Hazards are situ- ations or items that create danger and the potential for the disaster to occur. Hazard identification and analysis is the method by which planners identify which events are most likely to affect a community and serves as the foundation for decision making for prevention, mitiga- tion, and response. Hazards may include items such as chemicals used by local industry; transportation ele- ments such as subways, airports, and railroad stations; or collections of large groups of people in areas with limited access, such as skyscrapers, nursing homes, or sports stadiums (see Table 1.3). Environmental and me- teorological hazards must also be considered, such asFigure 1.5 New Orleans, LA, August 31, 2005—People walk the presence of fault lines and seismic zones and thethrough the New Orleans floodwaters to get to higher ground. seasonal risks posed by blizzards, ice storms, tornadoes,New Orleans was under a mandatory evacuation order as a hurricanes, wildfires, and heat waves. The National Fireresult of flooding caused by Hurricane Katrina. Protection Association’s Technical Committee on Disas-Photo by Marty Bahamonde. Source: FEMA, 2005 ter Management issued international codes and stan- dards that require a community’s hazard identification to include all natural, technological, and human haz- ards (NFPA, 2004).in addition to existing emergency medical services and Vulnerability is the “state of being vulnerable—should be set up no more than an hour’s walk from any open to attack, hurt, or injury” (Merriam Webster’s Col-location involved in the disaster to ensure maximum ac- legiate Dictionary, 2002). The disaster planning teamcessibility (Schultz, Koenig, & Noji, 1996). Casualty col- must identify vulnerable groups of people—those at par-lection points for both patients and health care providers ticular risk of injury, death, or loss of property from eachmay also need to be established in large-scale events hazard. Vulnerability analysis can provide predictions(see Figure 1.5). Potential collection points may include of what individuals or groups of individuals are mostgolf courses and shopping malls, or any large expanse of likely to be affected, what property is most likely to sus-open land capable of accommodating both ground and tain damage or be destroyed, and what resources will beair transport to serve as a staging area (Schultz et al., available to mitigate the effects of the disaster. Vulnera-1996). bility analysis should be conducted for each hazard that Information systems need to be identified or devel- is identified and must be regularly updated to accommo-oped that will track patients across multiple (and per- date population shifts and changes in the environmenthaps temporary) settings. Patient tracking during disas- (Landesman, 2001).ters is a major challenge because of lack of registration Risk assessment is an essential feature of disasterat shelters, and hospital communication systems that planning and is in essence a calculation or model ofdo not interface with other hospitals or county health risk, in which a comprehensive inventory is createddepartments. Family reunification was a major issue including all existing and potential dangers, the pop-following hurricanes Katrina and Rita, and has per- ulation most likely to be affected by each danger, andsisted as a major challenge to meaningful recovery initi- a prediction of the health consequences. Risk analysisatives. uses the elements of hazard analysis and vulnerability
  • 12 Part I Disaster Preparedness1.2 Methods for Data Collection for Disaster Planning 1.3 Hazard Analysis HAZARD IDENTIFICATION AND MAPPING Natural Events Hazard identification is used to determine which events are most Drought likely to affect a community and to make decisions about who or Wildfire (e.g., forest, range) what to protect as the basis of establishing measures for Avalanche prevention, mitigation, and response. Historical data and data Winter storms/blizzard: Snow, ice, hail from other sources are collected to identify previous and Tsunami potential hazards. Data are then mapped using aerial Windstorm/typhoon/cyclone photography, satellite imagery, remote sensing, and geographic Hurricane/typhoon/cyclone information systems. Biological event Heat wave Extreme cold VULNERABILITY ANALYSIS Flood or wind-driven water Vulnerability analysis is used to determine who is most likely to Earthquake be affected, the property most likely to be damaged or destroyed, Volcanic eruption and the capacity of the community to deal with the effects of the Tornado disaster. Data are collected regarding the susceptibility of Landslide or mudslide individuals, property, and the environment to potential hazards in Dust or sand storm order to develop prevention strategies. A separate vulnerability Lightning storm analysis should be conducted for each identified hazard. Technological events Hazardous material release RISK ASSESSMENT Explosion or fire Risk assessment uses the results of the hazard identification and Transportation accident (rail, subway, bridge, airplane) vulnerability analysis to determine the probability of a specified Building or structure collapse outcome from a given hazard that affects a community with Power or utility failure known vulnerabilities and coping mechanisms (risk equals Extreme air pollution hazard times vulnerability). The probability may be presented as Radiological accident (industry, medical, nuclear power plant) a numerical range (i.e., 30% to 40% probability) or in relative Dam or levee failure terms (i.e., low, moderate, or high risk). Major objectives of risk Fuel or resource shortage assessment include Industrial collapse Communication disruption Human events ■ Determining a community’s risk of adverse health effects due Economic failures to a specified disaster (i.e., traumatic deaths and injuries fol- General strikes lowing an earthquake) Terrorism (e.g., ecological, cyber, nuclear, biological, chemical) ■ Identifying the major hazards facing the community and their Sabotage, bombs sources (i.e., earthquakes, floods, industrial accidents) Hostage situation ■ Identifying those sections of the community most likely to be Civil unrest affected by a particular hazard (i.e., individuals living in or near Enemy attack flood plains) Arson ■ Determining existing measures and resources that reduce the Mass hysteria/panic impact of a given hazard (i.e., building codes and regulations Special events (mass gatherings, concerts, sporting events, for earthquake mitigation) political gatherings) ■ Determining areas that require strengthening to prevent or mitigate the effects of the hazard Source: Information obtained from Landesman, L. (2001). Chapter 5: Haz- ard assessment, vulnerability analysis, risk assessment and rapid health assessment. In Public health management of disasters: The practice guide. Washington, DC: American Public Health Association. The author grate- fully acknowledges Dr. Linda Landesman and the American Public Health Association for permission to reproduce this work.
  • Chapter 1 Essentials of Disaster Planning 13analysis to identify groups of people at particular risk Gans, 2001). Resources include both human and phys-of injury or death from each individual hazard. The cal- ical elements, such as organizations with specializedculation of estimated risk (probability estimate) may be personnel and equipment. Disaster preparedness shouldconstant over time, or it may vary by time of day, sea- include assembling lists of health care facilities; med-son, or location relative to the community (Gans, 2001). ical, nursing, and emergency responder groups; pub-Risk assessment necessitates the cooperation of corpo- lic works and other civic departments; and volunteerrate, governmental, and community groups to produce a agencies, along with phone numbers and key contactcomprehensive listing of all potential hazards (Leonard, personnel for each. Hospitals, clinics, physician offices,1991; Waeckerle, 1991). mental health facilities, nursing homes, and home care The following disaster prevention measures can be agencies must all have the capacity to ensure continuityimplemented following the analysis of hazards, vulner- of patient care despite damage to utilities, communica-ability, and risk: tion systems, or their physical plant. Communication systems must be put in place so that hospitals, health■ Prevention or removal of hazard (e.g., closing down departments, and other agencies both locally and re- an aging industrial facility that cannot implement gionally, can effectively communicate with each other safety regulations). and share information about patients in the event of■ Removal of at-risk populations from the hazard (e.g., a disaster. Within hospitals, departments should have evacuating populations prior to the impact of a hurri- readily available a complete record of all personnel, cane; resettling communities away from flood-prone including home addresses and home, pager, and cel- areas). lular phone numbers to ensure access 24 hours a day.■ Provision of public information and education (e.g., Resource availability will vary with factors such as time providing information concerning measures that the of day, season, and reductions in the workforce. Creativ- public can take to protect themselves during a tor- ity may be needed in identifying and mobilizing human nado). resources to ensure an adequate workforce (see Case■ Establishment of early warning systems (e.g., using Study 1.1). Disaster plans must also include alternative satellite data about an approaching hurricane for pub- treatment sites in the event of damage to existing health lic service announcements). care facilities or in order to expand the surge capacity■ Mitigation of vulnerabilities (e.g., sensors for venti- of the present health care system. lation systems capable of detecting deviations from Coordination between agencies is also necessary to normal conditions; sensors to check food, water, cur- avoid chaos if multiple volunteers respond to the disas- rency, and mail for contamination). ter and are not directed and adequately supervised. As■ Reduction of risk posed by some hazards (e.g., relo- with the 9/11 disaster, many national health care work- cating a chemical depot farther away from a school ers and emergency medical services responders who to reduce the risk that children would be exposed to came to New York to help returned because the numbers hazardous materials; enforcing strict building regula- of volunteer responders overwhelmed the local response tions in an earthquake-prone zone). effort.■ Enhancement of a local community’s capacity to re- spond (e.g., health care coordination across the en- tire health community, including health departments, CORE PREPAREDNESS ACTIVITIES hospitals, clinics, and home care agencies). 1) Theoretical foundation for disaster planning. Dis-Regardless of the type of approach used by planners aster plans are “constructed” in much the same way as(agent-specific or all-hazard), all hazards and potential one builds a house. Conceptually, they must have a firmdangers should be identified before an effective disaster foundation grounded in an understanding of human be-response can be planned. havior. Effective disaster plans are based on empirical knowledge of how people normally behave in disasters (Landesman, 2001). Any disaster plan must focus firstCAPACITY TO RESPOND on the local response and best estimates of what people are likely to do as opposed to what planners “want peo-Resource identification is an essential feature of disas- ple to do.” Realistic predictions of population behaviorster planning. A community’s capacity to withstand a accompanied by disaster plans that are flexible in de-disaster is directly related to the type and scope of re- sign, and easy to change, will be of greater value to allsources available, the presence of adequate communi- personnel involved in a disaster response.cation systems, the structural integrity of its buildings 2) Disaster planning is only as effective as the as-and utilities (e.g., water, electricity), and the size and sumptions upon which it is based. The effectiveness ofsophistication of its health care system (Cuny, 1998; planning is enhanced when it is based on information
  • 14 Part I Disaster Preparednessthat has been empirically verified by systematic field as a planning group to conduct the initial assessmentsdisaster research studies (Auf der Heide, 2002). Sound (risk, hazard, and vulnerability), establish a coordinateddisaster preparedness includes a comprehensive review process for response, design effective and complemen-of the existing disaster literature. tary communication systems, and create standard cri- 3) Core preparedness activities must go beyond the teria for the assessment of the scope of damage to theroutine. Most disasters cannot be managed merely by community.mobilizing more equipment, personnel, and supplies. 7) Identification and accommodation of vulnerableDisasters differ from routine daily emergencies, and they populations. A community disaster plan must accom-pose significant problems that have no counterpart in modate the needs of all people, including patients re-routine emergency responses. Many disaster-related is- siding in hospitals and long-term care facilities such assues and challenges have been identified in the disaster nursing homes, assisted living, psychiatric care facili-literature, and they can be anticipated and planned for ties, and rehabilitation centers. Children in residential(Auf der Heide, 2002). living centers, individuals detained in the criminal jus- 4) Community needs assessment. A community tice system, and prison populations must all be accom-needs assessment must be conducted to identify the modated within the plan. Poison control and suicidepreexisting prevalence of disease and to identify those hotlines need to be maintained, and the continuity ofhigh-risk, high-need patients that may need to be trans- home health care services must be safeguarded as wellported in the event of an evacuation or whose needs (see Case Study 1.2). School districts, day care centers,may necessitate the provision of care in nontraditional and employers must be kept aware and up to date re-sites. This needs assessment provides a foundation for garding the community’s disaster plan.planning along with baseline data for establishing the 8) State and federal assistance. Finally, state andextent of the impact of the disaster. federal assistance programs are added to the plan, and 5) Identify leadership and command post. The pro- consideration of the need for mutual aid agreements (be-cess of planning is often more important than the final tween communities or regions) is begun. Groups andwritten plan because those individuals who participate organizations are most helpful when they understandin the planning process will be more likely to accept their own capabilities and limitations, as well as thoseand abide by the final product. The issue of “who’s in of the organizations with which interactions are antic-charge” is critical to all components of the disaster re- ipated or intended. Disaster plans should be designedsponse and must be determined before the event occurs. to be both structured and flexible, with provisions madeThe process of disaster planning is important to estab- for plan activation and decision making by first-line em-lishing relationships, identifying leaders, and laying the ergency responders or field-level personnel, if necessary.groundwork for smooth responses. Identification of the 9) Identification of training and educational needs,command post must also be decided in advance and resources, and personal protective equipment (PPE).communicated to all members of the organization or The disaster plan provides direction for identifying train-community (see chapter 6 for further discussion). ing needs, including mock drills, and acquiring addi- 6) The first 24–48 hours: design of the local re- tional resources and PPE. A comprehensive discussionsponse. A plan for the mobilization of local authorities, of PPE is found in chapter 26.personnel, facilities, equipment, and supplies for the ini- 10) Plan for the early conduct of damage assess-tial postimpact 48-hour period is composed of the next ment. In emergency medical care, response time islevel of the foundation of the disaster response. Most critical (Schultz et al., 1996). A critical component todisaster casualties will arrive at the hospital within 1 any disaster response is the early conduct of a properhour of impact, and very few trapped casualties are res- damage assessment to identify urgent needs and to de-cued alive after the first day (Noji, 1996b). Thus, the termine relief priorities for an affected population (Lil-effectiveness of the local response is a key determinant libridge, Noji, & Burkle, 1992). Disaster assessment pro-in preventing death and disability (Auf der Heide, 2002). vides managers with objective information about theCommunities must be prepared to handle the immedi- effects of the disaster on a community and can beate postimpact phase in the event that they are also used to match available resources to the population’sisolated from outside resources or supplies (as hap- needs. The early completion of this task and the sub-pened in the immediate aftermath of 9/11 when all sequent mobilization of resources to areas of greatestplanes were grounded for the first time in U.S. avia- need can significantly reduce the adverse effects of ation history). This stage of the disaster planning will disaster. Identification of who will be responsible forinvolve many organizations and disciplines, from lo- this rapid assessment and what variables the assess-cal institutions to municipal, state, and federal govern- ment will contain needs to be identified in advance asments, including private, volunteer, and international part of the disaster planning process. Guha-Sapir (1991)agencies. First, local organizational leaders and execu- developed a template, or tool, from disaster epidemi-tives from each agency must come together and work ology that includes useful indicators for a rapid needs
  • Chapter 1 Essentials of Disaster Planning 15assessment after earthquakes and which can be used to resources is a common factor in many disasters; withoutestimate the following factors: experiencing at least some of the stress that accompa- nies that situation, it is unlikely that the disaster plan ■ Overall magnitude of the effect of the disaster (ge- and response will be taxed at a level that realistically ographical extent, number of individuals affected, simulates the circumstances of an actual disaster. estimated duration). Essential features of all effective disaster drills are ■ Effect on measurable health outcomes (deaths, ill- the inclusion of all individuals and agencies likely to nesses, injuries). be involved in the disaster response and a critique, ■ Integrity of the health care delivery system. with debriefing, of all participants following the exer- ■ Specific health care needs of survivors. cise. This should include representation from all sectors ■ Disruption of services vital to the public’s health of the emergency management field, all health care dis- (water, power, sanitation). ciplines, government officials, school officials, and the ■ Extent of response to the disaster by local author- media. The news media has a vital role in disasters, and ities. failure to include the media in planning activities can lead to a dysfunctional response (Auf der Heide, 2002). Regardless of the format used, the critique should con-EVALUATION OF A DISASTER PLAN sider comments from everyone involved in the drill. Dis- aster planners should review all observations and com-An essential step in disaster planning and preparedness ments and respond with modifications of the disasteris the evaluation of the disaster response plan for its ef- plan, if necessary. Any modifications made to disasterfectiveness and completeness by key personnel involved plans or response procedures must be communicatedin the response. The comprehension of people expected to all groups involved or affected. Periodic evaluationsto execute the plan and their ability to perform duties of disaster plans are essential to ensure that person-must be assessed. The availability and functioning of nel are adequately familiar with their roles in disasterany equipment called for by the disaster plan need to situations, as well as to accommodate changes in popu-be evaluated and reviewed on a systematic basis. Sev- lation demographics, regional emergency response op-eral methods may be used to exercise the disaster plan, erations, hospital renovations and closings, and otherthe most comprehensive of which would be its full im- variables. At a minimum, disaster drills should takeplementation in an actual disaster. Disaster drills may place once every 12 months in the community, and morealso provide an excellent means of testing plans for their frequently in hospitals and other long-term care facili-completeness and effectiveness. Drills can be staged as ties.large, full-scale exercises, using moulaged victims andrequiring vast resources of supplies and personnel, orthey may be limited to a small segment of the disas-ter response, such as drills that assess the effectiveness SITUATIONS SUGGESTIVE OF ANof communications protocols or notification procedures. INCREASED NEED FOR PLANNINGThe disaster plan also may be assessed by using “table-top” academic exercises, mock patients, computer sim- Disasters Within Hospitalsulations, or seminar sessions focusing on key personnelor limited aspects of the disaster response. Most hospital plans concern themselves with “exter- Improved performance during the drill, with en- nal” events, dealing specifically with the managementhanced understanding of disaster planning and re- of large volumes of patients arriving from an emergencysponse, is more likely when personnel are notified in that has occurred somewhere other than in the hospitaladvance that a drill is scheduled. The specific goal of (Aghababian et al., 1994). “Internal” disasters refer toany drill should be clearly communicated. If drills are incidents that disrupt the everyday, routine services ofto be used as training sessions as well as evaluations the medical facility and may or may not occur simulta-of preparations and response plans, personnel are more neously with an external event. Although these concur-likely to make the correct or most appropriate response rent events are rare, experiences such as the Northridgechoices during the drill if they are prepared. Frequent earthquake, Hurricane Andrew, and Hurricanes Katrinadrills will assure that knowledge and skills are current. and Rita are evidence that they can happen (AghababianConsequently, they will be more likely to take appro- et al., 1994; Quarantelli, 1983; Wolfson & Walker, 1993)priate actions when faced with an unexpected disaster with devastating consequences. Before Hurricane Kat-situation in the future. The more realistic the exercise, rina’s impact, there were 22 hospitals in New Orleans.the more likely it is that useful information about the Following the rupture of the levy, all 22 hospitals had tostrengths and weaknesses of both the disaster plan and be evacuated. Health care facilities need to define whatthe responders will be acquired. A shortage of available constitutes an internal disaster. In general, an internal
  • 16 Part I Disaster Preparednessevent can be defined as any event that threatens the ■ toxic exposures involving fumes, chemicals, or radi-smooth functioning of the hospital, medical center or ation;health care facility, or that presents a potential danger to ■ immediate evacuation of all patients and personnel.patients or hospital personnel (Aghababian et al., 1994).In the United States, the Joint Commission on Accredita- Internal disaster plans should be integrated with thetion of Healthcare Organizations (JCAHO) requires that hospital’s overall disaster preparedness protocol. Train-all hospitals have comprehensive plans for both inter- ing should be mandatory for all personnel. As with othernal and external disasters. A copy of the current JCAHO disaster plans, drills should be designed and routinelystandards for hospital disaster preparedness and a de- performed to ensure that all staff are adequately pre-tailed discussion of these guidelines can be found in Ap- pared (see chapter 6 for a detailed discussion of thependix XIV. Internal disasters or system support failures management of internal disasters).can result in a myriad of responses, such as evacuationof patients and staff; decreased levels of service pro-vision; diversion of ambulances, helicopter transport, Bioterrorism/Communicable Diseaseand other patients; and relocation of patient care areas.Sources of internal events include power failures, flood, Infectious disease outbreaks create unique challengeswater loss, chemical accidents and fumes, radiation ac- to planners. At what point does outbreak managementcidents, fire, explosion, violence, bomb threats, loss become disaster management? The investigation andof telecommunications (inability to communicate with management of any communicable disease outbreak re-staff), and elevator emergencies. The hospital setting is quires three steps: (a) recognition that a potential out-full of flammable and toxic materials. The use of lasers break is occurring; (b) investigation of the source, modenear flammable gases, multiple sources of radiation, of transmission, and risk factors for infection; and (c)storage of toxic chemicals, and potentially explosive implementation of appropriate control measures. If out-materials in hospitals and medical centers, magnifies break management exceeds or threatens to exceed thethe potential for a catastrophic event. Internal disaster capability and resources of the institution, then a disas-plans are based on a “Hospital Incident Management ter management model may be useful (Moralejo, Rus-System” and address the institution’s response to any sell, & Porat, 1997).potential incident that would disrupt hospital function- Institutional outbreaks of communicable diseaseing. Similar to the disaster continuum, the phases of a are common. Most institutional outbreaks involve rel-hospital’s internal disaster response plan generally in- atively few cases with minimum effect on the hospitalclude the identification of a command post and the fol- and external community. However, large outbreaks, out-lowing three phases: breaks of rare diseases, smaller outbreaks in institutions lacking infection control departments, or outbreaks in1) Alert phase, during which staff remain at their regu- those with inadequate infection control personnel may lar positions, service provision is uninterrupted, and exceed an institution’s or a community’s coping capac- faculty and staff await further instructions from their ities (Moralejo et al., 1997). The need for widespread supervisors. quarantine for the purposes of disease control (e.g.,2) Response phase, during which designated staff report smallpox epidemic) would rapidly overwhelm the ex- to supervisors or the command post for instructions, isting health care system and create significant staffing the response plan is activated, and nonessential ser- issues. Staff may refuse to come to work, fearing expo- vices are suspended. sure to themselves and their families. Health care facil-3) Expanded response phase, when additional person- ities play a vital role in the detection and response to nel are required, off-duty staff are called in, and ex- biological emergencies, including new emerging infec- isting staff may be reassigned based on patient needs tions, influenza outbreaks, and terrorist use of biological (see chapter 6). weapons. Assessment of the preparedness and capacity Internal disaster plans must address all potential of each hospital to respond to and treat victims of anscenarios, including infectious disease outbreak or biological incident must be conducted as part of disaster planning. The Agency■ loss of power, including auxiliary power; for Healthcare Research and Quality (AHRQ, 2002) re-■ loss of medical gases; leased a survey tool that was widely used by hospitals■ loss of water and/or water pressure; and health care facilities to assess their capacity to han-■ loss of compressed air and vacuum (suction); dle potential victims of bioterrorist attacks. In 2006, the■ loss of telecommunications systems; Agency for Healthcare Research and Quality issued a■ loss of information technology systems; report entitled “Altered Standards of Care in Mass Ca-■ threats to the safety of patients and staff (violence, sualty Events” with respect to bioterrorism and other terrorism, and bombs); public health emergencies (AHRQ, 2005).
  • Chapter 1 Essentials of Disaster Planning 17 victim decontamination and PPE into the planning pro-Hazardous Materials Disaster Planning cess (Levitin & Siegelson, 1996, 2002). A detailed dis- cussion of hazmat and patient decontamination is foundEvery industrialized nation is heavily reliant on chem- in chapter 26.icals. The United States is no exception; it produces,stores, and transports large quantities of toxic industrialagents. In fact, hazardous materials are present in everysector of American society and represent a unique and PROFESSIONAL NURSING MANDATEsignificant threat to civilians, the military, and healthcare workers both in the field and in the hospital emer- Caring for patients and the opportunity to save livesgency department. Situations involving hazardous ma- is what professional nursing is all about, and disasterterials suggest a need for additional planning efforts events provide nurses with an opportunity to do both.(Levintin & Siegelson, 1996, 2002). The chemical in- According to the American Nurses Association (ANA),dustry and the U.S. government have been making sub- “the aim of nursing actions is to assist patients, familiesstantial efforts since 9/11 to increase security prepared- and communities to improve, correct or adjust to physi-ness. Industry is carrying out joint assessments with cal, emotional, psychosocial, spiritual, cultural, and en-the Federal Bureau of Investigation; the Environmental vironmental conditions for which they seek help” andProtection Agency; Coast Guard; FEMA; the Bureau of definitions of nursing have evolved to acknowledge sixAlcohol, Tobacco and Firearms; and the Office of Home- essential features of professional nursing (ANA, 2003,land Security (Institute of Medicine, 2002). In the United pp. 1–5):States, the Superfund Amendment and ReauthorizationAct requires that all hazardous materials manufactured, ■ Provision of a caring relationship that facilitatesstored, or transported by local industry that could affect health and healing.the surrounding community be identified and reported ■ Attention to the range of human experiences and re-to health officials. Gasoline and liquid petroleum gas sponses to health and illness within the physical andare the most common hazardous materials, but other social environments.potential hazards include chlorine, ammonia, and ex- ■ Integration of objective data with knowledge gainedplosives. Situations involving relocation of nuclear from an appreciation of the patient or group’s subjec-waste materials also pose a considerable risk to the tive experience.communities involved. Material safety data sheets stan- ■ Application of scientific knowledge to the processesdardize the method of communicating relevant informa- of diagnosis and treatment through the use of judg-tion about each material—including its toxicity, flamma- ment and critical thinking.bility, and known acute and chronic health effects— ■ Advancement of professional nursing knowledgeand can be used as part of the hazard identification through scholarly inquiry.process. ■ Influence on social and public policy to promote so- Clinically, the removal of solid or liquid chemi- cial justice.cal agents from exposed individuals is the first stepin preventing serious injury or death. Civilian hazmatteams generally have basic decontamination plans in All nurses should have an awareness of the basicplace, though proficiency may vary widely (Institute of life cycle of disasters, the health consequences associ-Medicine, 1999). Few teams are staffed, trained, and ated with the major events, and a framework to sup-equipped for mass decontamination. Hospitals need to port the necessary assessment and response efforts. Sev-be prepared to decontaminate patients, despite plans eral nursing organizations have focused on the need forthat call for field decontamination of patients prior to improved disaster nursing preparation. The ANA, thetransport. Currently, few hospitals in the United States Emergency Nurses Association (see Case Study 11.1),are prepared to manage this type of disaster. During a and the Association for Professionals in Infection Con-hazmat accident, the victims often ignore the rules of trol and Epidemiology have each issued position state-the disaster plan by seeking out the nearest hospital for ments regarding the need for nurses to advance theirmedical care, regardless of that institution’s capabili- disaster knowledge and preparedness skills. In addition,ties. If health care providers rush to the aid of contam- the National Student Nurses Association also recognizedinated individuals without taking proper precautions the need to prepare itself for practice in disaster settings(e.g., donning PPE), they may become contaminated— (see Case Study 1.2). Although not all nurses will wantthe newest victims (Levitin & Siegelson, 1996). Because to become “disaster” nurses, it is imperative that eachmismanagement of a hazmat incident can turn a con- nurse acquire a knowledge base and minimum set oftained accident into a disaster involving the entire com- skills to enable them to plan for and respond to a disas-munity, disaster planning initiatives must incorporate ter in a timely and appropriate manner.
  • 18 Part I Disaster Preparedness sources to help develop a plan for another major S U M M A R Y event? 10) Describe the impact nursing involvement can haveDisasters are highly complex events that bring signif- in each of the five focus areas of disaster planningicant destruction and devastation to the communities and response.they strike. A disaster’s immediate effects may be seenin injuries and deaths, disruption of the existing healthcare system and public health infrastructure, and so-cial chaos. Effective planning for disaster preparednessshould be based on the fundamentals of disaster knowl-edge and an understanding of how people behave dur- I N T E R N E T A C T I V I T I E Sing a disaster situation. Disasters often share a commonset of problems and challenges that can be addressed 1) Go to the National Traffic and Road Closure In-during the planning process. formation Web site at http://www.fhwa.dot.gov/ trafficinfo/index.htm. In the event of a natural dis- aster involving severe weather conditions, locate updated information on the status of roads in your state and locality. What other Web sites could you go S T U D Y Q U E S T I O N S to for current weather-related road conditions during a disaster? What aspects of a disaster plan would this 1) Differentiate between “disaster,” “hazard,” and information change? “complex emergency.” What are the criteria used to 2) Go to the FEMA Web site at http://www.fema.gov/ classify the different types of disasters into cate- pdf / library / fema strat plan fy03–08(no append). gories? Explain how these unique features provide pdf. Review FEMA’s Strategic Plan for fiscal years a structure for strategic planning. 2003–2008 entitled “A Nation Prepared.” Describe 2) What is the disaster continuum, and what are the the agency’s goals and objectives. What is the all- five foci of disaster management? hazard management system and who is involved? 3) Compare and contrast risk assessment, hazard iden- How would you integrate this federal plan into a tification, and vulnerability analysis. local or regional disaster plan? 4) The Southport County Health Department is holding 3) FEMA is organized around four functional divisions a planning meeting with key public health officials that correspond to the phases of a disaster. Those are and health care clinicians to address disaster pre- Mitigation Division, Preparedness Division, Recovery paredness. Southport is a town of 28,000 in north- Division, and Response Division. Why isn’t there an west Montana and has experienced five blizzards Evaluation Division? Do you think that FEMA should and one flood in the past 3 years. Using the five fo- establish an Evaluation Division? How quickly could cus areas of disaster planning, construct a disaster FEMA accomplish this? response plan for this community. 4) Also located within the FEMA Web site is infor- 5) Why is the disaster planning process so important? mation regarding essentials of disaster planning for 6) What are some of the common problems, issues, vulnerable populations. Find “Disaster preparedness and challenges associated with disaster response? for people with disabilities” (http://www.fema.gov/ How can these problems and issues be addressed library/disprepf.shtm. Describe the care of the vul- during the preparedness phase? nerable following Hurricanes Katrina and Rita. Draft 7) What types of activities should a community pre- a proposal for disaster preparedness that includes pare for during the first 24 hours following impact identification of high-risk, high-vulnerability individ- of a disaster? uals in your community, mapping of their location, 8) Following Hurricane Andrew in south Florida, more and detailed plans for meeting their needs during a than 1,000 physicians’ offices were destroyed or disaster. significantly damaged. What impact did this have 5) Visit the U.S. Department of Health and Human Ser- on the burden of the health care system, and vices, Office of Public Health Emergency Prepared- what kind of planning could have mitigated this ness at http://www.hhs.gov/ophep/. What is the effect? purpose of this agency? Find the National Disaster 9) Following Hurricane Katrina all of the hospitals lo- Medical System (http://www.ndms.dhhs.gov/index. cated in New Orleans had to be evacuated. You are html). Why was this system developed, and what are a nurse working on Louisiana’s Gulf Coast and are the responsibilities of the teams? How do you join concerned that another hurricane may hit. What are a team? How are teams notified of current national you doing to prepare? Where would you find re- conditions?
  • Chapter 1 Essentials of Disaster Planning 19REFERENCES Lechat, M. F. (1990). Updates: The epidemiology of health effects of disasters. Epidemiology Review, 12, 192–197.Agency for Healthcare Research and Quality (AHRQ). Leonard, R. B. (1991). Emergency evacuations in disasters. Pre- (2002). Bioterrorism emergency planning and preparedness hospital Disaster Medicine, 6, 463. questionnaire for healthcare facilities. Retrieved from http:// Levitin, H. W., & Siegelson, H. J. (1996). Hazardous materials: www.ahrq.gov/about/cpcr/bioterr.pdf Disaster medical planning and response. Emergency MedicineAgency for Healthcare Research and Quality (AHRQ). (2005). Al- Clinics of North America, 14(2), 327–347. tered standards of care in mass casualty events. Rockville, MD. Levitin, H. W., & Siegelson, H. J. (2002). Hazardous materials dis-Aghababian, R. V., Lewis, C. P., Gans, L., & Curley, F. J. (1994). asters. In D. E. Hagan & J. L. Burstein (Eds.), Disaster medicine Disasters within hospitals. Annals of Emergency Medicine, 23, (pp. 258–273). Philadelphia: Lippincott, Williams & Wilkins. 771–777. Lillibridge, S. A., Noji, E. K., & Burkle, F. M. (1992). DisasterAl-Madhari, A. F., & Zeller, A. Z. (1997). Review of disaster defi- assessment: The emergency health evaluation of a disaster site. nitions. Prehospital Disaster Medicine, 12, 17. Annals of Emergency Medicine, 22, 1715–1720.American Nurses Association (ANA). (2003). Nursing’s social pol- Merriam Webster’s Collegiate Dictionary. (2002). Retrieved 3/7/07 icy statement (2nd ed.). from http://www.merriamwebster.com/Auf der Heide, E. (1989). Disaster response: Principles of prepara- Moralejo, D. G., Russell, M. L., & Porat, B. L. (1997). Outbreaks tion and coordination. St. Louis, MO: Mosby. can be disasters: A guide to developing your plan. Journal ofAuf der Heide, E. (1996). Disaster planning. Part II: Disaster prob- Nursing Administration, 27(7/8), 56–60. lems, issues, and challenges identified in the research liter- National Fire Protection Administration (NFPA). (2004). 1600 ature. Emergency Medicine Clinics of North America, 14(2), Standard on Disaster/Emergency Management and Business 453–475. Continuity Programs. Quincy, MA.Auf der Heide, E. (2002). Principles of hospital disaster planning. Noji, E. K. (1996). Disaster epidemiology. Emergency Medicine In D. E. Hogan & J. L. Burstein (Eds.), Disaster medicine. Clinics of North America, 14(2), 289–300. Philadelphia: Lippincott Williams & Wilkins. Noji, E.K. (1997). The nature of disaster: General characteristicsBerggren, R. (2005). Hurricane Katrina: Unexpected necessities— and public health effects. In E. K. Noji (Ed.), The public health Inside Charity Hospital. New England Journal of Medicine, consequences of disasters. New York: Oxford University Press. 353(15), 1550–1553. Parillo, S. J. (1995). Medical care at mass gatherings: Considera-Cuny, F. C. (1998). Principles of disaster management. Lesson 2: tion for physician involvement. Prehospital Disaster Medicine, Program planning. Prehospital Disaster Medicine, 13, 63. 10, 273.Federal Emergency Management Agency (FEMA). (1996). Guide Quarantelli, E. (1983). Delivery of emergency medical care in dis- for all-hazards emergency operations planning. Retrieved from asters: Assumptions and realities. New York: Irvington Pub- http://www.fema.gov/pdf/rrr/slg101.pdf lishers.Federal Emergency Management Agency (FEMA). (2000). Effec- Robert T. Stafford Disaster Relief and Emergency Assistance Act, tive disaster warnings. Available from http://www.fema.gov Pub. L. No. 93–288 (1988).Gans, L. (2001). Disaster planning and management. In A. Sabatino, F. (1992). Hurricane Andrew: South Florida hospitals Harwood-Nuss & A. Wefton (Eds.), The clinical practice of shared resources and energy to cope with storm’s devastation. emergency medicine (3rd ed., pp. 1702–1705). Philadelphia: Hospitals, 66(24), 26–30. Lippincott, Williams & Wilkins. Schultz, C. H., Koenig, K. L., & Noji, E. K. (1996). Current con-Garshnek, V., & Burkle, F. M. (1999). Telecommunication systems cepts: A medical disaster response to reduce immediate mor- in support of disaster medicine: Applications of basic informa- tality after an earthquake. New England Journal of Medicine, tion pathways. Annals of Emergency Medicine, 34, 213. 334(7), 438–444.Gordis, L. (2004). Epidemiology (3rd ed.). Philadelphia: W. B. Waeckerle, J. F. (1991). Disaster planning and response. New Eng- Saunders. land Journal of Medicine, 324, 815.Guha-Sapir, D. (1991). Rapid needs assessment in mass emergen- Wolfson, J., & Walker, G. (1993). Hospital disaster preparedness: cies: Review of current concepts and methods. World Health Lessons from Hurricane Andrew. Florida Public Health Infor- Statistics Quarterly, 44, 171–181. mation Center, College of Public Health, University of SouthInstitute of Medicine. (1999). Chemical and biological terrorism. Florida, Tampa, FL. Washington, DC: National Academy Press.Institute of Medicine. (2002). Making the nation safer: The role of science and technology in countering terrorism. Washington, DC: National Academy Press.Kim, D., & Proctor, P. (2002). Disaster management and the emer- ADDITIONAL READINGS gency department: A framework for planning. Nursing Clinics Emergency Management Standards of the Joint Commission on of North America, 37(1), 171–188. Accreditation of Health Care Organizations (JCAHO). (2001).Landesman, L. Y. (2001). Public health management of disasters: Comprehensive accreditation manual for hospitals. The practice guide. Washington, DC: American Public Health Emergency Management Standards of the Joint Commission on Association. Accreditation of Health Care Organizations (JCAHO). (2002).Landesman, L. Y., Malilay, J., Bissell, R. A., Becker, S. M., Roberts, Revisions to the Comprehensive accreditation manual for hos- L., & Ascher, M. S. (2001). Roles and responsibilities of public pitals. health in disaster preparedness and response. In L. F. Novick & Joint Commission on Accreditation of Healthcare Organizations. J. S. Marr (Eds.), Public health issues in disaster preparedness: (2005). Standing together: An emergency planning guide for Focus on bioterrorism (pp. 1–56). Gaithersburg, MD: Aspen. America’s communities. Retrieved 3/7/07 from http://www.Lechat, M. F. (1979). Disasters and public health. Bulletin of the jcaho.org/about+us/public+policy+initiatives/planning World Health Organization, 57(1), 11–17. guide.pdf
  • 20 Part I Disaster Preparedness CASE STUDY 1.1 FEMA: The Disaster Process and Disaster Aid ProgramsResponse and Recovery agreement to commit state funds and resources to the long-term recovery.First response to a disaster is the job of local govern- ■ FEMA evaluates the request and recommends actionment’s emergency services with help from nearby mu- to the White House based on the disaster, the localnicipalities, the state, and volunteer agencies. In a catas- community, and the state’s ability to recover.trophic disaster, at the request of the governor, federal ■ The president approves the request or FEMA informsresources can be mobilized through the U.S. Depart- the governor it has been denied. This decision processment of Homeland Security’s Federal Emergency Man- could take a few hours or several weeks, dependingagement Agency for search and rescue, electrical power, on the nature of the disaster.food, water, shelter, and other basic human needs. It isthe long-term recovery phase of disaster that places themost severe financial strain on a local or state govern-ment. Disaster Aid Programs A major disaster could result from a hurricane,earthquake, flood, tornado, or major fire that the presi- There are three major categories of disaster aid:dent determines warrants supplemental federal aid. Theevent must be clearly more than state or local gov- Individual Assistance. Immediately after the declaration,ernments can handle alone. If declared, funding comes disaster workers arrive and set up a central field officefrom the president’s Disaster Relief Fund, which is man- to coordinate the recovery effort. A toll-free telephoneaged by FEMA, and disaster aid programs of other par- number is published for use by affected residents andticipating federal agencies. business owners in registering for assistance. Disaster A presidential major disaster declaration puts into Recovery Centers also are opened where disaster victimsmotion long-term federal recovery programs, some of can meet with program representatives and obtain in-which are matched by state programs, and designed to formation about available aid and the recovery process.help disaster victims, businesses, and public entities. Disaster aid to individuals generally falls into the An emergency declaration is more limited in scope following categories:and without the long-term federal recovery programs ofa major disaster declaration. In general, federal assis- ■ Disaster housing may be available for up to 18tance and funding are provided to meet a specific emer-gency need or to help prevent a major disaster from months, using local resources, for displaced per-occurring. sons whose residences were heavily damaged or des- troyed. Funding also can be provided for housing repairs and replacement of damaged items to makeThe Major Disaster Process homes habitable.A major disaster declaration usually follows these steps: ■ Disaster grants are available to help meet other se- rious disaster-related needs and necessary expenses not covered by insurance and other aid programs.■ Local government responds, supplemented by neigh- These may include replacement of personal property, boring communities and volunteer agencies. If over- transportation, and medical, dental, and funeral ex- whelmed, turn to the state for assistance. penses.■ The state responds with state resources, such as the ■ Low-interest disaster loans are available after a disas- National Guard and state agencies. ter for homeowners and renters from the U.S. Small■ Damage assessment by local, state, federal, and vol- Business Administration (SBA) to cover uninsured unteer organizations determines losses and recovery property losses. Loans may be for repair or replace- needs. ment of homes, automobiles, clothing, or other dam-■ A major disaster declaration is requested by the gov- aged personal property. Loans are also available to ernor, based on the damage assessment, and an businesses for property loss and economic injury.
  • Chapter 1 Essentials of Disaster Planning 21■ Other disaster aid programs include crisis counseling, for public schools. Learn more about public assistance disaster-related unemployment assistance, legal aid, at http://www.fema.gov/government/grant/pa/index. and assistance with income tax, Social Security, and shtm. Veteran’s benefits. Other state or local help may also be available.■ After the application is taken, the damaged prop- erty is inspected to verify the loss. If approved, an Hazard Mitigation. Disaster victims and public entities applicant will soon receive a check for rental assis- are encouraged to avoid the life and property risks of tance or a grant. Loan applications require more in- future disasters. Examples include the elevation or relo- formation and approval may take several weeks after cation of chronically flood-damaged homes away from application. The deadline for most individual assis- flood hazard areas, retrofitting buildings to make them tance programs is 60 days following the president’s resistant to earthquakes or strong winds, and adoption major disaster declaration. and enforcement of adequate codes and standards by local, state, and federal government. FEMA helps fund Audits are done later to ensure that aid went to only damage mitigation measures when repairing disaster-those who were eligible and that disaster aid funds were damaged structures and through the hazard mitigation.used only for their intended purposes. These federalprogram funds cannot duplicate assistance provided byother sources such as insurance. Contact Information for FEMA: After a major disaster, FEMA tries to notify all dis-aster victims about the available aid programs and urge General Questionsthem to apply. The news media are encouraged to visit FEMA-Correspondence-Unit@dhs.gova Disaster Recovery Center, meet with disaster officials, Telephone: 1 (800) 621-FEMA (332)and help publicize the disaster aid programs and the TDD: TTY users can dial 1 (800) 462-7585 to use thetoll-free teleregistration number. Federal Relay Service. Fax: 1 (800) 827-8112Public Assistance. Public assistance is aid to state or lo-cal governments to pay part of the costs of rebuilding acommunity’s damaged infrastructure. In general, public Technical Assistance (Online Registration)assistance programs pay for 75% of the approved projectcosts. Public assistance may include debris removal, Telephone: 1 (800) 745-0243emergency protective measures and public services, re- Fax: 1 (800) 827-8112pair of damaged public property, loans needed by com- Federal Emergency Management Agencymunities for essential government functions and grants P.O. Box 10055 Hyattsville, MD 20782-7055Source: FEMA. (2006). Available at: http://www.fema.gov/library/dproc.shtm CASE STUDY National Student Nurses Association 2006 1.2 Resolution for Student Nurses Disaster and Emergency PreparednessJennifer Timony and territories who are enrolled in associate, baccalau-During the 2005–2006 academic year, I had the op- reate, diploma, and generic graduate nursing programs.portunity to serve as the Resolutions Chairperson for With its nationwide membership, the NSNA mentorsthe National Student Nurses’ Association (NSNA). The the professional development of future nurses and facili-NSNA is an organization of over 45,000 nursing stu- tates their entrance into the profession by providing edu-dents from the United States and its commonwealths cational resources, leadership opportunities, and career
  • 22 Part I Disaster Preparednessguidance. As the chairperson of the Resolutions Com- WHEREAS, professional nurses are often restrictedmittee I guided the legislative process of writing and to acute care settings in times of disasteradopting resolutions that would guide the future actions and crisis; andof the NSNA. At the midyear convention of the NSNA WHEREAS, student nurses are an available and com-in Kentucky, I conducted a workshop on the process petent resource to assist in disaster reliefof writing a resolution and sought out fellow students efforts; andto become the authors of quality materials for potential WHEREAS, no literature has identified the appropri-resolutions. Students were encouraged to return to their ate scope of practice to support studenthome states and begin research on significant topics for nurse utilization in the area of disasternursing students at the national level. relief; and Groups of students in Florida and Texas began WHEREAS, the lack of a defined scope of practicewriting about issues related to emergency and disas- for student nurses during disaster reliefter preparedness as a response to the great devastation operations is a repeated problem needingcaused by hurricanes and flooding in their areas. They attention and is likely to reoccur; andwanted to help after the hurricanes but were often met WHEREAS, the National Student Nurses’ Associationwith obstacles. The frustration created by these obsta- (NSNA) has for the past 53 years beencles led them to want to do more to make changes. the connecting link and collective bodyThey authored resolutions aimed at addressing potential of the state student nurses associationssolutions for emergency and disaster preparedness for promoting “civic responsibility”; there-nursing students. The next step was to combine theses fore be itresolutions into one comprehensive resolution to be pre- RESOLVED, that the National Student Nurses’ Asso-sented at the NSNA annual convention, which took ciation (NSNA) support education andplace in Baltimore, Maryland, in April 2006. The Res- awareness of the need for the establish-olutions Committee facilitated combining the material ment of protocols guiding the scope ofso it could be presented before the House of Delegates, practice for student nurses in the area ofthe voting body of the NSNA. The following is the res- disaster relief and the collection and dis-olution as it was presented. tribution of donations for disaster areas; and be it further RESOLVED, that the NSNA encourage its constituents to work collaboratively with their localTOPIC: IN SUPPORT OF THE ESTABLISHMENT and state disaster response and health- OF PROTOCOLS FOR DISASTER RELIEF care agencies to develop a taskforce that GUIDING THE SCOPE OF PRACTICE will define the scope of practice of stu- FOR STUDENT NURSES AND THE COL- dent nurses in disaster settings and de- LECTION AND DISTRIBUTION OF DO- velop a protocol for coordinating the col- NATIONS lection and distribution of donations toSUBMITTED Texas Student Nurses Association and be sent to disaster areas; and be it fur-BY: Valencia Community College Nursing ther Student Association RESOLVED, that the NSNA promote student involve-AUTHORS: Blair Baker, Jessica Jones, Millicent ment in community disaster response Jones, Jessica Macleary, Brieann Mellar, planning, implementation, and evalua- Starlit Monzingo, and Daniel Thurow tion, and the collection and distributionWHEREAS, student nurses have contributed to disas- of donations; and be it further ter relief from the time of The Jackson- RESOLVED, that the NSNA send a copy of this resolu- ville yellow fever epidemic of 1888; and tion to the President of the United States,WHEREAS, the American Red Cross recognizes the the American Nurses Association, the contributions of student nurses in “de- American Red Cross, the Federal Emer- livering critical community services for gency Management Agency, the Ameri- more than half a century”; and can Association of Colleges of Nursing,WHEREAS, the United States has experienced many the National League for Nursing, the Na- crisis events, both natural and man- tional Organization for Associate Degree made, within the past four years; and Nursing, state departments of health, theWHEREAS, no community is ever fully prepared to National Council of State Boards of Nurs- handle a massive disaster with a large ing, and all others deemed appropriate influx of patients; and by the NSNA Board of Directors.
  • Chapter 1 Essentials of Disaster Planning 23 Discussion at the Resolutions Hearings at the an- was discussed. This resolution was one of 15 adoptednual meeting of the NSNA centered on inspiring fel- out of a total of 19 presented before the House of Dele-low students to be visionaries and agents of change. gates.We were reminded to continue to advocate for our pa- The task set before the newly elected board mem-tients by furthering our education, becoming involved bers of the NSNA is to begin to creatively implementin our communities, and influencing future changes in the 2006 resolutions. The constituent chapters will benursing. Fellow students encouraged the NSNA mem- guided in constructing programs to implement the re-bers to endorse programs that are already in place that solved statements and to empower the membership toprovide disaster relief, training, education, and certifi- take personal action as well. We are all part of support-cation. Taking these steps in times of calm will allow ive communities, and we need to find creative ways tous to meet needs when there are emergencies or disas- give back.ters. Leadership by nurses in various community groupswill positively influence the changing image of nursing.Liability concerns were raised regarding nurses and stu- Source: National Student Nurses Association 2006 Resolutions.dents who are serving with the best of intentions. Na- Retrieved June 2, 2006, from http://www.nsna.org/pubs/pdf/tional consistency for scope of practice and licensure Resolution%202006.pdf
  • Key Messages ■ The National Disaster Response Framework includes emergency management authorities, policies, procedures, and resources of local, state, and federal gov- ernments, as well as voluntary disaster relief agencies, the private sector, and international resources to provide assistance following a disaster. ■ The Department of Homeland Security coordinates the National Response Plan (NRP) to provide supplemental assistance when the consequences of a disaster overwhelm local and state capabilities. ■ The NRP coordinates with other federal emergency plans as necessary to meet the needs of unique situations. ■ The NRP works hand-in-hand with the National Incident Management System and incorporates the tenets of the Incident Command System. ■ Nurses need to be aware of Emergency Support Function (ESF 8), Health and Medical Services, and its core provisions. ■ Nursing leadership during a disaster or mass casualty event demands a broad knowledge base and a unique skill set. ■ Changes in government structure in disaster response and in the public health system may create opportunities for nurses to act in new, yet-to-be defined roles. ■ Nurses must actively seek out positions of leadership in health policy and disaster management. ■ Nurses must remain vigilant as this information is constantly changing as health policy and federal restructuring continues.Learning Objectives When this chapter is completed, readers will be able to 1. Describe the medical services system. 2. Describe the National Response Plan and the National Incident Management Sys- tem. 3. List the 15 emergency support functions included in the plan, particularly the emergency support function (ESF) 8. 4. Discuss the purpose and scope of ESF 8. 5. List the federal definitions of a disaster condition. 6. Describe federal resources where nurses might volunteer, including the National Disaster Medical System, Medical Reserve Corps, and U.S. Public Health Service and its Federal Medical Shelters. 7. Identify challenges to health systems leadership and coordination. 8. Communicate the issues surrounding disaster nursing leadership.