Chapter 23- Public Health Nursing and the Disaster Management Cycle
Public health triage
"Triage is the process of prioritizing which patients are to be treated first and is the cornerstone of good disaster management in terms of judicious use of resources involves the sorting or identification of populations for priority interventions. In epidemics, for example, the public health triage focus becomes the prevention of secondary infection.
Pandemic
(of a disease) occurring throughout the population of a country, a people, or the world.
Healthy People 2020
- Disaster incidents have an effect on almost every objective. - Disasters play a direct role in the objectives related to the following: • Environmental Health • Food Safety • Immunization and Infectious Disease • Mental Health and Mental Disorders
Preparedness
- Disaster kits for home, workplace, and car
The main principles of triage
- Every patient should receive and triaged by appropriate skilled health‐care professionals. - Triage is a clinic - managerial decision and must involved collaborative planning - The triage process should not cause a delay in the delivery of effective clinical care.
Response
- First level: Is the Implementation of the disaster plan and mobilization of first responders ‐ local responders: Fire Dep't, Police, Public Health, and Emergencies services - National Response Framework (NRK) • Emergency support functions (ESFs) - National Incident Management System (NIMS) • BioWatch, BioSense, Project BioShield, Cities Readiness Initiative, Strategic National Stockpile (SNS)
Nuclear Power Plant Incident
- Harrisburg, PA: 3 Mile Island Nuclear- March 1979 - Chernobyl, Ukraine April 26, 1986 - Fukushima, Japan 2011
Prevention against human‐made disasters
- Heightened inspections - Improved surveillance and security operations - Public health and agricultural surveillance and testing - Immunizations -Isolation/Quarantine - Halting of Chemical, biological, radiological, nuclear, and explosive (CBRNE) threats
Community Phases of Disaster
- Heroic, - Honeymoon, - Disillusionment, - reconstruction
Need of the disaster Triage
- Inadequate resources to meet immediate needs - Infrastructure limitations - Inadequate hazard preparation - Limited transport capabilities - Multiple agencies responding - Hospital or Staging Facilitie's resources Overwhelmed
Need of the disaster Triage
- Inadequate resources to meet immediate needs - Infrastructure limitations - Inadequate hazard preparation - Limited transport capabilities - Multiple agencies responding - Hospital or Staging Faclities resources Overwhelmed
Professional preparedness
- National Disaster Medical System (NDMS) - Disaster Medical Assistance Team (DMAT) - Medical Reserve Corps (MRC) - Community Emergency Response Team (CERT) - American Red Cross (ARC)
Community Preparedness
- National Health Security Strategy (NHSS) - Disaster and mass casualty exercises • The National Exercise Program (NEP) • Homeland Security Exercise and Evaluation Program • Federal Emergency Management Agency (FEMA) --------- Regional Offices: X Seattle, WA; XI Oakland, CA; VIII Denver CO; VII Kansas City KS; VI Denton, TX; V Chicago, Ill; IV Atlanta, GA; III Philadelphia, PA; II New York, NY; I Boston, MA
types of disasters
- Natural - Accidental - Terrorist attack - bacteriological - topographical - Meteorological
Bombings
- Oklahoma City, OK April 19, 1995 - Murrah Fed Bldg. - New York, NY, September 11, 2001‐ Twin Towers - Boston, MA, April 15, 2013 - The Marathon
5 basic phases to a disaster management cycle
- Prevention - Mitigation - Preparedness - Response - Recovery
Aims of triage (mass casualty)
- To sort patients based on needs for immediate care - To recognize futility - Medical needs will outstrip the immediately available resources - Additional resources will become available given enough time
Phases of Disaster
- pre-disaster - Impact - Heroic - Honeymoon - Disillusionment - reconstruction
Accidental disaster
-caused by man-made events such as the chernobyl melt down or the BP oil spill. Chernobyl Accident, Post‐Tsunami ‐ Japan, Collapse of BP oil rig - Gulf of Mexico
bioterrorism
Bioterrorism event involves the intentional release of living organisms into the environment for the purposes of causing illness or death. - Biologic are air or waterborne and are inhaled or ingested. Incubations periods afford time to leave the scene before detection.
Meteorological
Blizzard 1888, Dust Bowl 1930s, Droughts - Africa, Bangladesh or smaller scale Texas/California, Tornado Alley ‐ USA
HUMAN‐GENERATED DISASTERS
Direct causes are identifiable human actions ‐ deliberate or otherwise Disasters caused by sociopolitical conflicts that escalate into violence. Conflict can result from economic measures such as boycotts and sanctions, e.g., Iraq & Cuba have been victims of medication boycotts from the USA; which results in humanitarian damage
Homeland Security Presidential Directive-21 (HSPD-21): Public Health and Medical Preparedness
Established a national strategy that Enables a Level of public health and medical preparedness sufficient to address a range of possible disaster. It did so to four critical components 1) *Bio-surveillance* enhance security, 2) *counter-measure distribution* 3) *Mass casualty care* 4) *Community resilience*
terrorist attack
French Revolution, WW I, 9 - 11 NYC, Boston Marathon, 2015 Paris Terror Attacks
Natural disaster
Great destruction or loss of life caused by natural forces rather than by human actions Floods, Fires, Tornados, Hurricanes Widespread throughout the world: Earthquake Haiti, Locusts swarms Madagascar, Isaac's Storm
Functional needs and support services (FSS)
Implemented to *aid individuals in maintaining their independence* with general populations Shelters.Required FSS include reasonable modification to policies, practices and procedures to accommodate individuals with functional needs as well as access to durable medical equipment within the shelter environment (e.g. Walkers, beds, ventilators), Consumable medical supplies (e.g. Ostomy supplies, dressings) All shelter residents should have access to personal assistance devices and other goods and services needed, And arrangements to make this . so must be made in advance
Four critical components to address a range of possible disasters
National Health Security Strategy (NHSS) enables a level of public health & medical preparedness to to address disasters using (1) biosurveillance, (2) countermeasure distribution, (3) mass casualty care, and (4) community resilience
Interprofessional
Nurses closely Work with interprofessional health teams, community leaders and organizations, engaging with and advocating for the client as needed across the disaster management cycle
bacteriological
Pandemics - world wide, i.e. Flu 1918, Tuberculosis ongoing, N1H1 2009 or Disease Epidemics - confined to smaller areas, i.e., Ebola, Malaria, Measles
Recovery
Returning to the new normal - Community balance of infrastructure and social welfare near the level that it would have had if the event had not occurred. • Hardest part of a disaster • Federal assistance - Rebuilding and restoring after large‐scale event • Gradual shift in support - From short‐term aid to long‐term support for communities: sustainment of effort
incident command system
Standardized approach to incident management that facilitates interaction between cooperating agencies; adaptable to incidents of any size or type. *operations* -Establishes strategy -Coordinates and execute strategies *Logistics* -Organizing use of personnel, supplies and equipment - Performs technical activities to maintain Functionality *Planning* - Coordinates support - Support operations in processing incident information - Coordinates information activities across the response team *Admin/Finance* - Support your administrative issues and tracking and processing incident expenses - Licensing requirements, regulatory compliance And financial accounting
National preparedness guidelines (NPG)
The national preparedness goal & nation response plan
alternate care centers
Used to shelter patients with medical needs designated as "non-ambulatory care/hospital overflow", For example care of a non-ambulatory patient with less intense medical needs. Federal medical stations FMS or another Alternate Care area for patients. These units provide basic care For non-ambulatory,Hospital overflow, Patients with minimal medical needs, and Shelter patients with more advanced medical needs. Requested by state health or emergency management agencies FMS are designed to plug and play in structures of opportunity in the community, such as schools or convention centers.
Topographical
Volcanic Eruptions - Mt St Helens, Mt Vesuvius (Italy), Super Volcanic Yellowstone; Earthquakes - Great Alaska Earthquake/tsunami
Homeland security exercise and evaluation program (HSEEP)
Was Created to *help States And local jurisdictions improve overall preparedness* with all natural and human made disasters The *national standard* for all exercise development and implementation Provide a *standardized methodology and terminology for exercise design, development, conduct, Evaluation, And Improvement planning And to assist communities to create exercises* that will make a positive differences before a real incidence
Gorilla war
a conflict of small, independent, partisan fighters who oppose a ruling government.
National response plan (NRP)
a national doctrine to include Emergency Support Function (ESF 8), Public Health and Medical(DHS, 2008a) ESF8 provides coordinated f federal assistance to supplement state, local, and tribal resources in response to public health and medical care needs. Updated to: • *National Response Framework *(NRF)‐Jan 2008 and remains a guide for conducting a nation‐wide all‐hazards response
*Armed conflict*
a term used to avoid national & international law concerning warfare.
Public Health Security and Bioterrorism Preparedness and Response Act of 2002
addressed the need to enhance public health and health care readiness and community health care infrastructures.
Robert T. Stafford Disease Relief and Emergency Assistance Act:
allows for governors to request federal assistance under a presidential disaster or emergency declaration when state resources and capabilities are overwhelmed.
Mitigation
an attempt to limit a disaster's impact on human health and community function.
BioWatch
an early warning system for bio threats that uses an environmental sensor system to test the air for biological agents in several major metropolitan areas. -sensors have the ability to autonomously sample the surrounding air, ID up to 100 diff biological threats and instantaneously share their findings to official
General population shelters
are often the responsibility of the local Red Cross chapter under the ESF 6 partner function. accommodate a variety of functional needs for individuals such as assistance with activities of daily living.
Disaster
are often unforeseen, serious, and unique events; disrupting essential community services and cause human morbidity and mortality that can not be alleviated unless assistance is received from others outside the community. They vary by: - type of onset (unusually no warning); - duration of immediate crisis; - magnitude or scope of incident; - extent affecting the Community.
Community resilience
builds on the premise that healthy individuals, families, and communities with access to health care and knowledge become some of our nation's strongest assets in disaster incidents. the time it takes for a community to bounce back to its original state after a disturbance
Human-made incident
causes disruption, destruction, and/or devastation requiring external assistance.
CBRNE threats
chemical, biological, radiological, nuclear, explosive - describes the full spectrum of munitions used to create a human-made disaster.
*War*
conflict between to large groups of population, which involves physical force, and use of weapons.
National Health Security Strategy (NHSS)
connected with public health and medical preparedness, response and recovery strategies. focuses specifically on the national goals for protecting people's health in the case of disaster in any setting. I national strategy That enables a level of public health and medical preparedness sufficient to address range of possible disasters For critical components: 1)Bio surveillance 2)counter-measure distribution 3)Mass casualty care 4)Community resilience Is updated every four years
Homeland Security Act of 2002
creation of the Department of Homeland Security consolidated more than 20 separate agencies into one unified organization. To Prevent, Protect against, mitigate the effects of, respond to, and recover from those Threats that pose the greatest risk to the security of the nation
Triage
deciding which injured or sick individuals need the most immediate attention and by whom.
Riots
defines the moment when a protest or an act of civil disobedience escalates into violence (between 2 crowds), either accidentally or on purpose. The violence can be initiated by either the protesters or by the police. Motivation is often political, but also can be the result of mass hysteria , e.g., during a soccer game or political rally. They can begin as a peaceful march or protest and end as a riot - 1965 Selma to Montgomery March known as 'Bloody Sunday' or 2016 Baltimore Orioles and Chicago White Sox game closed to public.
independence war
describes efforts of a population or people defending their own state against an occupying force.
Public health surge
describes the ability to provide adequate medical evaluation and care during events that exceed the limits of the normal medical infrastructure of an affected community overwhelming need for medical assistance during an emergency.
Special needs shelters
designed for those individuals who have pre-existing conditions resulting in medical impairments and who have been able to maintain activities of daily living in a home environment prior to the disaster or emergency situation.
Human-made disaster
destruction or devastation caused by humans.
Homeland Security Presidential Directive-5 (HSPD-5)
directed by Secretary of Homeland Security to develop and administer the NIMS. *National Incident Management System (NIMS)* - was established to provide a *common language and structure* enabling all those involved in disaster response the ability to *communicate* together more effectively and efficiently.
Crisis Standards of Care
enable the health care operations necessary to allocate scarce resources in a different manner to save as many lives as possible.
Mutual aid agreements
establish relationships between partners prior to the incident at the local, regional, state, and national levels and ensure seamless service. Local responders Within the country signed many regional/statewide Agreement National. Allow the *sharing of needed personnel, equipment, services and supplies*
National Preparedness Guidelines (NPG)
established national guidelines to strengthen the preparedness of the United States to protect against, respond to, and recover from threatened or actual terrorist attacks and major disasters. * Organize and synchronize national (including Federal, State, local, tribal, and territorial) efforts to strengthen national preparedness; * Guide national investments in national preparedness; * Incorporate lessons learned from past disasters into national preparedness priorities; * Facilitate a capability-based and risk-based investment planning process; and * Establish readiness metrics to measure progress and a system for assessing the Nation's overall preparedness capability to respond to major events, especially those involving acts of terrorism.
Vicarious traumatization
for nurses during a disaster/ incident, this occurs in response to listening to survivors' stores of the traumatic event. Therefore, mental health workers need to assist nurses as well as the public. Severe stress caused by exposure to traumatic images or stories that cause the observer to become engaged with the stressful material
Rapid needs assessment
includes : determining of the magnitude of the incident, defining the specific health needs of the affected population, establishing priorities and objectives for action, identifying existing and potential public health problems, evaluating the capacity of the local response including resources and logistics, and determining the external resource needs for priority actions.
Strategic National Stockpile (SNS)
is a CDC- managed program with the capacity to provide large quantities of medicine and medical supplies to protect the American public in a public health emergency to include bioterrorism. The SNS is deployed through a combination of state level request and the public health system.
BioSense
is a data-sharing program to facilitate surveillance of unusual patterns or clusters of diseases in the United States. It shares data with local and state health departments and is a part of the BioWatch system.
Cities Readiness Initiative
is a program to aid cities in increasing their capacity to deliver medicines and medical supplies during a large-scale public health emergency such as a bioterrorism attack or a nuclear accident.
Project BioSheild
is a program to develop and produce new drugs and vaccines as countermeasures against potential bioweapons and deadly pathogens.
BioWatch
is an early warning system for biothreats that uses an environmental sensor system to test the air for biological agents in several major metropolitan areas.
Point of Dispensing (POD)
locations throughout the County which could be used to distribute medications in the event of a health emergency. the state and local emergency planners ensure this to provide prophylaxis to the entire population within 48 hours.
American Red Cross
one of more than 120 national organizations that seek to reduce human suffering through various health, safety, and disaster relief programs in affiliation with the international Red Cross and Red Crescent Societies. It is not a government agency. The American Red Cross has more than 1.2 million members throughout the United States. Some 97% of Red Cross staff is volunteer. The American Red Cross blood program collects and distributes more blood than any other single U.S. agency and coordinates distribution of blood and blood products to the U.S. Defense Department on request or during national emergencies. American Red Cross nursing and health programs include *courses in the home on parenthood, prenatal and postnatal care, hygiene, and venereal disease.* Nursing students may enroll for service in American Red Cross community programs and during disasters. The symbol of the American Red Cross, like that of most other Red Cross societies throughout the world, is a red cross on a field of white.
Personal protective equipment (PPE)
operate specialized equipment needed to perform specific activities, and safely perform duties in disaster environments.
Public Health Nursing Intervention Wheel
population-based practice model that encompasses three levels of practice (community, systems, and individual/ family) and 16 public health interventions. Each intervention and practice level contributes to improving population health, providing a practice foundation.
Community Emergency Response Team (CERT)
programs sponsored by the Federal Emergency Management Administration (FEMA) to *train community citizens* in the basics of disaster preparedness and response. Using the training, members can assist their neighbors and co-workers following an event when professional responders are not immediately available to help.
Medical Reserve Corps (MRC)
provide opportunities for nurses to support emergency preparedness and response in their local jurisdictions. Medical volunteer agency that is committed to supporting public health and emergency response in the community.
Emergency Support Functions (ESFs)
provides coordinated *federal assistance to supplement* state, local, and tribal resources in response to public health and medical care needs fifteen functions used in a federally declared disaster. Each function is headed by a primary agency.
National Disaster Medical System (NDMS)
provides nurses the opportunity to work on specialized teams such as the DMAT. Agency that maintains a database of trained on-call medical, paramedical, and allied health personnel for emergency deployment during a disaster. (NDMS) a federally coordinated system establishing a single, integrated national medical response capability for assisting state and local authorities in dealing with the medical impacts of disasters
Psychological first aid
psychological first aid is establishing the safety of the client, reducing stress-related symptoms, providing rest and physical recuperation, and linking clients to critical resources and social support systems. Paramount is attending to Maslow's needs of hierarchy and taking care of survival needs first.
disaster management cycle
real time event of a hazard occurring and affecting the 'elements at risk'. The duration of the event will depend on the type of threat, for example ground shaking may only occur for a few seconds during an earthquake while flooding may take place over a logner period of time.
one health
recognition that human health, animal health, and ecosystem health are inextricably linked The goal of One Health is to encourage the collaborative efforts of multiple disciplines-working locally, nationally, and globally-to achieve the best health for people, animals, and our environment.
National Response Framework (NRF)
remains a guide for conducting a nationwide all-hazards response, "build upon scalable, flexible, and adaptable coordinating structures to align key roles and responsibilities across the Nation, linking all levels of government, nongovernmental organizations, and the private sector". describes not only how the Federal government organizes itself to respond to natural disasters, terrorist attacks, and other catastrophic events but also the importance of the whole community in assisting with response efforts Each Framework covers one preparedness mission area: Prevention, Protection, Mitigation, Response or Recovery.
Disaster Medical Assistance Team (DMAT)
teams of *specially-trained civilian physicians, nurses, and other health care personnel who are sent to a disaster*.
Risk communication
the exchange of information about health or environmental risks among risk assessors and managers, the general public, news media, interest groups, and so on.
Bioterrorism
the intentional use of a pathogen or biological product to cause harm to a human, animal, plant, or other living organism in order to influence the conduct of government or to intimidate or coerce a civilian population.
Emergency operations center
this is the facility that houses communication equipment , plans, contact notification list and staff that are used to coordinate the response to an emergency. The physical location at which the coordination of information and resources to support incident management (on-scene operations) activities normally takes place. An EOC may be a temporary facility or may be located in a more central or permanently established facility, perhaps at a higher level of organization within a jurisdiction. EOCs may be organized by major functional disciplines (e.g., fire, law enforcement, medical services), by jurisdiction (e.g., Federal, State, regional, tribal, city, county), or by some combination thereof.
Disaster Response Ethics:
understanding that in time of disaster, not everyone will receive all the care that they would under normal condition. Instead, the focus is on providing care that maximizes the benefit to the greatest number of people. Also, it is vital that the nurse owes the same duty to self as others.
Homeland Security Exercise and Evaluation Program (HSEEP)
was developed to *help states and local jurisdictions improve overall preparedness* with all natural and human-made disasters.
Homeland Security Presidential Directive-8 (HSPD-8)
was established in December of 2003. It established *national policies* to strengthen the preparedness of the United States to prevent, protect against, respond to, and recover from threatened or actual terrorist attacks and major disasters, and it included a goal for national preparedness.
National Incident Management System (NIMS)
was established to provide a common language and structure enabling all those involved in disaster response the ability to communicate together more effectively and efficiently. The purpose of the NIMS is to provide a common approach for managing incidents. The concepts contained herein provide for a flexible but standardized set of incident management practices with emphasis on common principles, a consistent approach to operational structures and supporting mechanisms, and an integrated approach to resource management.
Pandemic and All- Hazards Preparedness Act (PAHPA)
which was enacted in 2006 to improve the nation's ability to detect, Prevent,prepare for, and respond to , and Recover from a variety of public health emergencies.
Heroic:
• An overwhelming need for people to do whatever they can to help others survive the disaster • First responders, including health and medical personnel, will work hours on end with no thought of their own personal or health needs (fighting sleep, refusing breaks) • Exhausted overworked responders are a danger to themselves and the community served
- Bioterrorists attacks by small radical Political Fractions:
• First recorded occurred in 184 BC - Hannibal used snakes • 1984 Salmonella used to contaminate salad bars in 10 eateries in Oregon. • 1993 Anthrax release in Tokyo without infecting anyone • 1995 Sarin released in a Tokyo subway • 20001 Anthrax spores were mailed to news offices and 2 US senators Terrorism has once again shown it is prepared deliberately to stop at nothing in creating human victims. End must be put to this. As never before, it is vital to unite forces of the entire world community against terror - Vladimir Putin
POPULATIONS AT RISK IN DISASTERS
• Individual health characteristics, persons with conditions that put them at risk, such as those with chronic disease, elder persons, or children, are among the most vulnerable in any society concerning impact of disaster • 95% of deaths that result from natural disasters occur among 66% of the world's poorest population - Likely to live in substandard housing with little structure - Often live in coastal locations that are at high risk for disasters - Likely to live in flood plains and other less desirable land - Likely to live in substandard housing built on unstable geographical slopes - Likely to live near hazardous industrial sites - Not usually educated about safe & appropriate life‐saving behaviors - Are more dependent on others for transportation (Lundy & Janes 2009)
- Reconstruction:
• Longest phase • Homes, churches, schools, etc. need to be rebuilt and reestablished • The goad is to return to a new state of normal
Disillusionment:
• Occurs as time elapses and people notice that additional help and reinforcement are not coming as fast as the initial response • Fatigue and gloom start to take a toll on volunteers and workers • The community begins to realize that a return to the previous normal state is unlikely and that they must make major changes and adjustments
How Disasters Affect Communities
• One Health and interconnectedness • Stress reactions in individuals - Exacerbation of a chronic disease - Older adult's reactions dependent on health, independence, income, etc. - Regressive behaviors in children - The population at greatest risk for disruption • Single‐parent families, Children, substance abusers, • Compromised immune system (chemo, HIV, etc.
Disaster Management
• Prevention (Mitigation and Protection) • All - hazards mitigation (prevention) - Reducing risks to people and property from natural hazards before they occur • Prevention against natural disasters - Protecting buildings and infrastructure - Threats include forces of wind and water • Nonstructural measures - Land development restrictions
Honeymoon:
• Survivors may be rejoicing that their lives and loved ones have been spared • They gather to share • Repeating stories creates bonds among survivors • A sense of thankfulness is apparent in their stories
Management of Mass Casualties
• The goal in a mass casualty incident is to maximize the number of lives saved and to do the greatest good for the greatest number of individuals. • Institute of Medicine (IOM), in 2012 recommended *Crisis Standards of Care* : enable the health care operations necessary to allocate scarce resources in a different manner to save as many lives as possible. • "*Triage* is the process of prioritizing which patients are to be treated first and is the cornerstone of good disaster management in terms of judicious use of resources (Auf de Heide, 2000).
Management of Mass Casualties ‐ *Simple*
• This can begin before transportation becomes available • The categorization of patients based on the severity of their injuries can be aided with the use of printed *triage tags or colored flagging* • *S.T.A.R.T. (Simple Triage and Rapid Treatment)* is a simple system that can be performed by lightly trained lay and emergency personnel in emergencies: *0*‐dead/beyond help; *1*‐injured can be helped by immediate transportation; *2*‐ injured transport can be delayed and *3*‐minor injuries, who need help less urgently*
Individual and Family Preparedness
• Training in first aid • Assisting in disaster relief efforts require you be healthy as possible, both physically and mentally • Assembling a disaster emergency kit for home, workplace, and car • Making a family plan - Establishing a predetermined meeting place away from home - Making a family communication plan - Making a contingency plan for children, older adults, and pets • Professionally‐ be knowledgeable of their facility's & community disaster plans & evaluate performance through participating in mock disaster drills
*Civil war*
• is defined as a conflict between 2 opposed parties in 1 country - may receive support from external parties representing certain political interests.
