Are you Ready ???

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Are you Ready ???

• Evacuation of a 130 Bed Skilled Nursing Facility

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Linden Grove Health Care Center Puyallup, WA

• Flood Evacuation January 2009
• Dianna Hart, ARNP, Interim Administrator
• Lisa Johnson, RN, DNS
• Erwin Steinlein, Director
• Environmental Services, Health Safety

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• The Puyallup River river is approximately ½ mile
  from the facility
• The initial estimated flood crest of 39 feet
  could have resulted in 1-2 feet of water in our
  facility

Due to the situation an evacuation order was
initiated by the City of Puyallup Emergency
Management
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• To relocate 99 wheel chair bound residents to a
  shelter required the assistance of Pierce County
  Transit Shuttles.
• Each shuttle transported 5 wheel chair bound
  residents 1 employee
• In addition 24 of our most acute residents
  required ambulance transportation to our sister
  facility.

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• Nursing Medical 1st Priority
• Dietary 2nd PriorityThese items included
  specialty needs which Red Cross would not have
  been able to supply. Items such as thickened
  liquids, food blenders, diabetic items, and
  special diet needs.

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• Due to limited time, resident personal items
  could not be packed for evacuation. Using the
  unmarked clothing racks allowed us to gather warm
  cloths for immediate use.

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• Preparing resident loading.
• One check out station for residents going to the
  shelter.
• Resident charts medication cards were placed in
  bags attached to the back of each wheel chair.
• A triple check of residents was accomplished
  prior to departing the facility.

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• A single line operation was used for loading of
  residents. This allowed one side of the hall to
  remain open for other emergency operations.

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Evacuation ShelterInitial Set-up Bed down
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Nurse Station Set-up Organization
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Sleeping ArrangementsNOTE Cots are grouped in
clusters of Four
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• We began transporting residents back from the
  shelter using our facility bus. As we waited for
  assistance from Pierce County Transit Shuttles.

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Pierce County Transit Support during Recovery
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Recovery with aid of Puyallup Central Pierce
Co. Fire Departments
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Department/Manager Debrief 1/12/09

• During the months of October and November 2008
  Department/Manager staff had completed Incident
  Command System (ICS) training and Table Top
  Exercises

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Department/Manager Roundtable Debrief
1/12/09Issues/Recommendations

• Key Points.The facility Incident Command (ICS)
  should have been activated when the situation
  elevated from flood watch to flood warning. If
  the facility IC had been activated many of the
  problems we encountered would not have occurred.
  
• NOTE The facility was given 45 minutes to begin
  the evacuation process.

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COMMUNICATION ISSUES

• Some residents felt we could have had more direct
  communications with them. They felt more updates
  of the situation could have been provided.
• Family Notifications The facility could not
  contact some families due to disconnected
  numbers, etc...
• Handling high volume of incoming calls
  dissemination of messages received. During the
  process the main lobby area became very congested
  and loud making it difficult for the
  receptionist.-- Suggest forward calls from the
  main lobby reception desk to an office area.--
  Advise sister facilities Corporate offices to
  call an alternate number. We have two fax line
  numbers that can be used with analog phones in
  the Nurse Case managers office.
• Difficulties with communicating with Command
  General Staff The facility does not have
  radios so we had to physically hunt down and
  send runners to communicate.

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Communications cont....

• Lack of direct contact with key personnel of the
  ICS Command staff and the co-located Director of
  Nursing (Operations) at the Shelter.
• The use of personal cell phones created
  communication breakdowns. At one point the DNS
  (Operations _at_ Shelter) was using three different
  cell phones
• Dissemination of key information was hampered
  because of busy signals
• Most of the cell phones did not have chargers
• No way to Talk group (three way call) all key
  staff at one time.-- One suggestion is
  standardizing all Revera cell phones or a minimum
  of three per facility to one carrier that has,
  Push to Talk and Blackberry capabilities. Such
  as Nextel/Sprint. The Push to Talk can be
  configure to reach out Nationwide provides the
  capability to one touch group call.
• Lack of IT support at the Evacuation Shelter. The
  Administrators lap top should have wireless
  capability. If this situation would have been
  expanded in time the ability to access internet
  operations and other reporting and information
  agencies would be non-existent.

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Administration Issues

• Missing payroll edit slips for employees _at_
  shelter
• Office support items at the Shelter, i.e.... hole
  punch, pens, paper, etc...
• A system to identify resident sleeping
  arrangements at the Shelter.
• --- To address these issues we will assemble a
  Mobile office deployable kit. The kit(s) will
  be stocked with necessary items and located in
  the Emergency supplies shed.
• Lack of accountability of who was in or out of
  the facility during the evacuation (family,
  friends, employee spouses and volunteers).--
  The facility will go into a full secure condition
  for all exit doors. One person will be stationed
  to monitor the facility door alarms and advise if
  they are breached. Exits used for evacuation will
  be monitored by a single staff member. All
  non-emergency responders will sign in/out.
• Residents discharged in care of family members
  will assemble at a predetermined location for the
  following
• Nurse to provide discharge instructions,
  discharge documentation, final check of
  medication requirement, ensure medical records do
  not go with resident for all that will NOT be
  evacuated to a shelter.

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Medical Supplies

• Shortfalls in the central supply area.
• The Central Supply person was out ill. Preparing
  needed supplies took a long time to ready for the
  evacuation (labeling issues).
• Cross training was already started but not fully
  in-place to address this issue.
• Lack of organization.
• -- For some supplies we did not have enough and
  others entirely too much-- Hard to locate items
  that were on-site at the shelter-- No tracking
  mechanism of what went out in support of shelter
  operations.-- Missing items _at_ shelter, i.e....
  IV pumps, TF pump, IV supplies, just to name a
  few.
• -- Workable method to store and dispense
  medications _at_ shelter
• -- Workable method to transport medications.--
  Separation of personal care items from other
  medical supplies
• -- No means of keeping required medications
  cool. (We were lucky that this shelter had a
  refrigerator we were able to use)

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Medical Supplies

• The following are to address some of the
  shortfalls we encountered.
• 1. Inventory and reorganize the medical supplies
  shed.2. Reorganize the medical supplies
  storage.3. Establish minimum supply levels for
  Attends, wipes, and personal care items and
  store in Emergency Supply shed.4. Separate
  ALL items using color coded bins. Example, O2
  items in green bins, syringes and flush items in
  white bins. These bins will be filled and located
  in the Emergency Supplies shed.5. Develop
  required supplies inventory list and deployment
  checklists6. Laminated inventory lists in
  numerous locations such as, the administrative
  deployment kit, central supply, Emergency supply
  shed.7. Develop supplies check out/in list.
  Tracks what, when and with who8. Using the
  facility ICS assign staff to fill departing and
  receiving positions9. Procure specialty bins
  for medications which can be effectively utilized
  for transport and to disperse medications.10.
  Procure small ice chest for each unit to store
  refrigerated medications.11. Procure and store
  Dry Ice in the facility Walk-in Freezer for
  emergencies12. Procure sets of cotton sweats
  (100-120). Store in vacuum sealed bags.13.
  Develop a supply rotation spreadsheet of items in
  Emergency shed with a shelf life.

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Supplies Laundry, Activities, Dietary

• Laundry Too much for the location, need better
  transport mechanism, need to separate by item
  type.
• Items were transported in can liners and was very
  bulky and hard to handle.-- Without knowledge of
  receiving shelter assets, more blankets, sheets,
  and pillows were deployed than needed from the
  facility. -- Supplies, such as, blankets,
  sheets and pillows, will be placed in vacuum
  sealed bags and stored with deployable items in
  the Emergency shed.
• Dietary Deployable assets came from inventory
  stock. Means of transport and organization is
  required.-- Procure bins for emergency use.
  Empty bins will be stored in the Emergency
  shed.-- Develop master supply checklist for both
  food and equipment needs. Note, we will always
  prepare to feed altered textures and special
  needs diets.
• Activities comfort and activity items.--
  Develop a master checklist of supplies.--
  Procure bins. Empty bins will be stored in the
  Emergency shed

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Nursing/Medical Records/Documentation

• Minor issues with transportation. Ambulance
  priority based on medical such as, acuity,
  isolation, etc... .
• Documentation requirements for EMR transport. It
  was uncertain if standard EMR transport documents
  would be required during an emergency.
• Issues with resident arm bands. We had to remake
  a few arm bands during the evacuation.
• Lacked extra forms at the shelter.-- Extra Forms
  to track who had meals _at_ shelter-- Extra Forms
  to manage altered and special diets _at_ shelter
• Means to label resident beds with key information
  such as, O2, diabetic, diet, etc...
• Provide a better means of holding medications and
  records. Paper bags were used which worked, but
  are not good in the rain

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Nursing/Medical Records/Documentation cont...

• Suggestions to address issues--- Modify daily
  census to include clinical issues with resident.
  Examples IV, TF, infections, and extra equipment
  needs.--- Assign Case Manager/Unit Nurse to
  perform discharge of residents leaving with with
  family to further enhance our current procedures
  to expedite discharge to home.
• --- Develop checklist for required documentation
  by type of transport.--- Procure different types
  of arm bands for residents.--- Assemble Medical
  Forms deployable kit with extra forms.---
  Procure water proof bags to hold charts
  medications.

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ICS Command

• Problems with relocating high acuity residents to
  our Sister Facility. --- Revise facility daily
  census sheet to reflect acuity of residents. This
  would give anyone in the facility information
  needed for transportation request and sheltering
  needs.When given an Evacuation order numbers
  are critical for transportation sheltering.
• First team out did not have medical equipment
  needed. (i.e. BP cuffs, scanners, test
  equipment).--- Reassess the Medical 1st out
  team equipment list and assemble a 1st out
  Medical deployable kit to store in the Emergency
  shed.
• No master list available for deployable
  assets.--- Develop IC books for Command staff.
  These will have copies of all the department
  checklist, Command instruction checklist
  Emergency phone lists. Basically a TO-DO step
  by step check off list by priority.
• At the initial notification to evacuate we
  experienced some confusion. --- STOP, assess the
  situation, and then proceed with actions
  required. --- The IC Command staff books will
  assist us with moving in the right direction
  regardless of the type of emergency.

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Sheltering Issues

• Some cots were 30-36 inches high which created
  transferring issues to and from wheel chairs to
  cots. In addition we were unsure of cot weight
  capacity.
• Toileting of residents was difficult with only 2
  bathrooms.
• Space limitations. Once cots were assembled very
  little space remained open.
• Unknown if emergency power was available in the
  event of a power outage. KEY ISSUE power is
  needed for IV pumps, Concentrators, and feeding
  pumps.
• Need for additional electrical support. As a
  precautionary measure we deployed our facility
  emergency power kit to the shelter. The kit
  contains extension cords, extra flash lights,
  glow sticks, and surge suppressors that were all
  used through the evening to support operations.
• Although there were issues, the shelter staff and
  volunteers provided a safe warm environment for
  our residents and staff.

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Conclusion

• Even though we had some minor shortfalls the
  overall Evacuation went extremely well. The mass
  evacuation of over 120 residents with
  disabilities is not an easy task to perform.
• The facility had recently begun training on the
  change over from the Chain of Command to the
  Incident Command System for Disaster Response.
  Having the base knowledge of the workings of the
  ICS is one reason we were able to perform as well
  as we did. The other key factors for our success
  were
• EMPLOYEES, VOLUNTEERS, PIERCE COUNTY EMD, CITY OF
  PUYALLUP EM, PIERCE COUNTY TRANSIT AND ALL THOSE
  WHO PROVIDED ASSISTANCE AT THE SHELTER

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Questions Discussion
Revera Health Systems
400 29th St NE Puyallup WA 98372 [phone]