Disaster%20Preparedness

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Disaster Preparedness

• Garry Hagstrom, MD
• Stephen Fadem, MD

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Disaster Preparedness

• Recent experience with Katrina, Rita, Ike
• 44 missed 1 or more treatments
• Usually new patients to dialysis most likely to
  miss
• When interviewed 1 out of 3 patients said they
  were unaware of disaster instructions

Studies indicate that up to 44 of patients
missed one or more treatments following the
hurricanes. This study also found that most
patients who missed were new to dialysis. That is
they had started dialysis in the last two years.
It appears that patients who have recently
started dialysis tend to underestimate the
necessity of their routine treatments. There has
been significant preparation by dialysis
personnel for impending disaster. However, when
interviewed 1 or 3 said they were unaware of
plans or disaster instructions. This underscores
the need to reinforce information given to
patients.
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OUR GOAL IS TO REVIEW DISASTER PREPAREDNESS
PLANNING FOR THE CKD PATIENT AND THE NURSING ROLE
IN PRE AND POST DISASTER

4
In the first presentation you get a sense of what
it is like when a unit was closed, severely
damaged or was a responder. After going through
this presentation you should be able to

• LIST THE THREE SECTIONS YOU CAN USE TO THINK
  ABOUT DISASTERS
• KNOW WHAT R.E.A.D.Y. STANDS FOR
• KNOW WHAT WEB RESOURCES ARE AVAILABLE TO HELP YOU

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DISASTER MANAGEMENT

• Prepare before disaster
• Managing during disaster
• Assessing after disaster

When preparing for disaster it is best to divide
into three sections. Preparing before the
disaster, managing during the disaster and
assessing after the disaster.
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Before Disaster

• Be sure staff and patients know plans
• Give explicit dietary instructions
• Encourage evacuation when indicated
• Develop phone lists and phone trees
• Pre-prepare public service announcements
• Notify critical services of emergent needs

When planning be sure the staff and patients know
the plans and how to implement. Be sure and give
specific dietary instruction and give written
mater to the patients. Encourage the patients to
evacuate when they are told to. But, realize that
many patients wont evacuate even when told to so
make plans appropriately. Develop phone lists and
duplicates and plan phone trees so the work load
is distributed to multiple employees' is a good
idea to pre-prepare a public service
announcement and distribute this to authorities
before the disaster. This is important as most
lines of communications may be down during the
disaster. It is critically important to notify
critical services of your need to have emergent
provision of services. Including electricity,
water, transportation. Dialysis units are not
usually included in this list.
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Before the disaster
History of Gulf storms and ESRD

• 30 years ago, Medicare envisioned disasters as a
  major problem. A 143 page booklet has features
  still salient today. They mention the importance
  of communication recommending Walkie Talkies.
• The modern era of disaster preparedness began in
  Florida, which probably has had the most
  experience with hurricanes. However, it was
  Hurricane Katrina which put disaster management
  in public focus.
• Houstonians have always had a collaborative
  spirit. In 2001 Dr. Hagstrom was picking up
  staff in his ¾ ton truck during the flood while
  Dr. Fadem was running a phone bank and making
  television announcements for patients. During
  Katrina Baylor ran the shelters at the Astrodome
  while UT ran those at George R. Brown. Many
  doctors and nurses either spent the night at
  shelters, hospitals or dialysis units.
• In the wake of Hurricanes Katrina and Rita, the
  Centers for Medicare Medicaid Services held
  regular conference calls with staff and
  stakeholders. Government and NKF worked to create
  a listserv and daily calls. Through the sharing
  of information and services was born the Kidney
  Community Response Coalition a group with
  representatives from more than 50 governmental
  agencies, private organizations and foundations
  that have worked hard together in preparing for
  disasters. KCER is focused on preparedness for
  patients, responders, and potential victims. It
  has developed communication networks and worked
  with state and local officials to recognize the
  needs of patients with kidney disease. It has
  developed explicit plans for prospective evacuees
  and first responders. In addition, the ESRD
  Network of Texas worked closely with large
  dialysis organizations like DaVita and local
  dialysis centers to establish different criteria
  for those who must evacuate and those who would
  be first responders. The Texas Emergency ESRD
  Coalition and KCER also works with state and
  local organizations that would be involved in
  rescue efforts and reestablishment of vital
  services.

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Before Disaster

• Mitigation for damage
• Remember safety of patients and staff
• Prepare to minimize any damage done to your
  facility, your personnel your equipment. Drape
  machines in plastic. Board up windows. This is
  important as little help will be available during
  or after the event.

The coordination efforts by TEEC are critical.
If hospitals and dialysis units are communicating
regarding supplies, resources and personnel
things can go much more smoothly. Before the
storm pre-prepare announcements, set up networks
and develop relationships. Make sure staff and
patients are aware of plans. Set up phone numbers
and phone trees with redundancy because during
the storm electricity and other services will
probably be unavailable. The one thing that is
predictable is that the storm is not predictable
will it be winds or floods or both? How much
damage? What services and supplies will be
available?
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Before Disaster - Evacuate

• Evaluation should be done prior to the call for a
  mandatory evacuation because of the possibility
  of a traffic jam
• Patients should have a contact in a nearby city
  and make arrangements in advance in case they
  must leave.

In Houston, the freeways were jammed during
Hurricane Rita with many who did not need to
evacuate. By using effective communications with
local media, experts were able to advise
residents by zip code who should be evaluated
during Ike. The contra flow routes were not
required, and traffic moved, albeit slowly, for
those in need of leaving. Disaster kits with
lavender wrist bands and fanny packs were
distributed to each dialysis patient so that they
could be readily identified. Many patients
decided to leave the area early, visiting friends
and relatives in surrounding Texas towns. In most
facilities, dialysis treatments were truncated so
that patients who would require dialysis during
the storm could be brought in early. Patients
were advised regarding fluids, dietary
restrictions, and keeping their medications safe
and nearby. Source NephrOnline, Hurricane Ike
What we learned 12/11/2008 Stephen Z. Fadem, M.D.

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During Disaster

• Utilize plans made
• Organize staff that is able to be present
• If plan isnt working improvise!!!
• Experience suggests hard working staff and
  knowledgeable patients will keep things running
• Triage is vital
• Patient and staff attitudes are vital

When the disaster has struck immediately utilize
the plans you have made. Whatever staff is able
to arrive, organize them to various jobs. They
will probably need to have tunnel vision and stay
focused on their job. If you find your plan is
not meeting your requirements no problem
improvise. Some of the best plans and
organization has come with emergent needs. Our
experience suggest that very hard working staff
will overcome most problems. Also very knowledge
and cooperative patients are vital. This is an
emergency so triage is important .
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During Disaster

• As possible contact patients
• You cant fix everything immediately Do your
  best
• Utilize public agencies (emergency services)
• Medical Directors need to be there
• Share Large dialysis chains and independents
  need to share available resources and balance
  patient loads

As you have time try and contact your patients to
see how they are, if they can come, when they can
come etc. Remember you cannot fix everything
immediately so do the best you can. There are
multiple public emergency services, utilize them.
They are available. Many times political
officeholders are out and assisting and they can
get immediate assistance. Also remember all of us
(dialysis providers, patients ) are in this
together. Share the resources. Patients may be
from other units, supplies may need to be shared
etc.
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During Disaster

• Medical Directors need to be there

The LDOs were active participants in KCER, and
created networks and hotlines to assist patients.
The Networks have always played a large role in
disaster preparedness, relief, and recovery.
Prior to the storm, patients and their social
workers made plans so that in many facilities,
the teammates knew exactly where the patients
would be. In some situations, there was
confusion, but for most it went smoothly.
Emergency response assessments immediately after
the storm determined which units could open. With
no power, generators were dispatched from
neighboring cities and auxiliary power, even
Internet services were up and running within a
few days in several facilities. Some facilities
were not as fortunate, and remain closed,
particularly on Galveston. Those patients were
relocated to alternate facilities. CJ Flenneken,
a facility administrator, deserves tremendous
credit for coordinating many of these efforts and
for keeping DaVita Medical Center operational and
prepared as an active first-responder facility.
Several physicians, such as Drs. Gary Hagstrom,
Juan Olivero and Robert Durrett, worked
tirelessly to accommodate guest patients.Many
physicians spent the entire weekend in the
hospitals triaging patients who arrived with
hyperkalemia. Special mention should be made to
Dr. Joey Buquing who spent the long weekend in
service at Methodist Hospital.physicians spent
the entire weekend in the hospitals triaging
patients who arrived with hyperkalemia. Special
mention should be made to Dr. Joey Buquing who
spent the long weekend in service at Methodist
Hospital. Source NephrOnline, Hurricane Ike
What we learned 12/11/2008 Stephen Z. Fadem, M.D.

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Luck Saved the Day

• Ike hit Galveston and then Houston on September
  13, 2008. On Monday the power throughout Houston
  was out because of downed trees and massive
  damage of substations. Centerpoint and Reliant
  were working full steam, and linemen from around
  the country were coming here to help.
• Despite multiple efforts previously to set up
  dialysis as the highest priority, confusion at
  the utility companies meant information about the
  needs of dialysis patients was never passed
  along. Furthermore, a 72 station dialysis center
  would need the equivalent of six generators one
  the size of an 18 wheeler. FEMA was not helpful.
  Most numbers did not work, but a 911 call about
  our desperate situation landed Dr. Hagstrom in
  touch with the Mayors office, and an aid was
  able to find a generator from Whole Foods. It
  took five electrical lines to connect it, but
  DaVita Med Center the major responder unit for
  miles around had electricity.

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Post Disaster

• What worked and what didnt
• Meetings are usually held to discuss results- GO
• Modify plans made as necessary

After the disaster and after you have physically
and emotionally rested, sit down and go over the
event. Analyze what went right and what went
wrong. How can you improve what was done, what
needs to be changed. Usually there are meeting
after the event to discuss it. Attend those
meeting as you may receive new information, new
methods, facts you didnt know. Then sit down
with all the information and redo your plans.
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READYA useful pneumonic for the patient to
remember is READY

• R is for RX The patients needs to have all
  their medications (at least a one week supply on
  hand)In addition they need a list of all there
  medications with dosages, allergies, refills.
  Also their personal physicians so that the
  responding physician has someone to contact for
  questions
• E is for emergency. In case they cannot contact
  any dialysis facility or company they can go to
  emergency room. However, the ER will be crowded
  and it is very difficult for them to care for
  large groups of patients.
• A is for access. They need to know how to
  contact their dialysis units and how the unit can
  contact them.
• D is for diet . The patient needs to know what
  foods can be eaten what foods to avoid. In
  addition they need to know foods that dont
  require refrigeration.
• Y is for You. Know what you are going to do, who
  you are going to stay with.

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Are you R.E.A.D.Y.

• R is for Rx
• E is for ER in emergency
• A access (phone numbers)
• D diet and liquids
• Y is for YOU (make plans to be with
  someone)

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Your patients need at least one week supply of
medications. If they run out, many of the
shelters have doctors who can help. Be sure they
they have their primary care nephrologist, PCP
and other specialists names and phone numbers
handy
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Are you R.E.A.D.Y.

• R is for Rx
• E is for ER in emergency
• A access (phone numbers)
• D diet and liquids
• Y is for YOU (make plans to be with
  someone)

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Sourcehttp//www.uhd.edu/
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Are you R.E.A.D.Y.

• R is for Rx
• E is for ER in emergency
• A access (phone numbers)
• D diet and liquids
• Y is for YOU (make plans to be with
  someone)

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Build a phone tree

• Do not rely on just one number
• Have several numbers
• Cell phone numbers
• Out of town numbers
• Dont just rely on your iPhone you may have
  electricity

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Are you R.E.A.D.Y.

• R is for Rx
• E is for ER in emergency
• A access (phone numbers)
• D diet and liquids
• Y is for YOU (make plans to be with
  someone)

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Patients (and staff) should go to the supermarket
early and stock up on water and nonperishable
foods, as well as other supplies they will need.
Once supplies are depleted, it will be difficulty
for stores to replenish since their employees are
evacuating and roads will be blocked. Several
websites give lists of what is needed during
disaster preparation. http//72hours.org is an
excellent resource.
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Dont forget your pets needs?
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Dont forget the pet
Dont forget your pets needs?
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1 gallon of water per week each that is 8 500
cc bottles
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Excellent non perishable food
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Make certain to stock up on non-perishable foods
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Sorry the freezer probably will not have
electricity for a few weeks
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Sorry - Perishables should be enjoyed before the
storm.
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Go Kit

• One gallon of water per day eight bottles
• Ready to eat, non perishable food (dont forget
  the can opener
• Plates, utensils and feeding supplies
• Work gloves
• Disposable camera
• Personal hygiene items
• hand sanitizer
• Duct tape, hammer, nails, tools
• Sleeping bag

• Flashlights and batteries
• Battery operated radio
• Whistle
• Dusk mask
• Pocket knife
• Cash
• Good sturdy shoes, clothing
• Hat
• Map, paper, Sharpie
• Waste bucket
• Plastic bags
• Small shovel

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Patients and staff should pack a GO bag with
necessary supplies in advance
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Go Kit

• One week supply of medications
• Prescriptions
• Contact numbers doctors, dialysis personnel,
  corporate numbers, emergency numbers (Network)
• Health insurance card
• Prescription for glasses
• Extra pair of eyeglasses
• Dialysis information
• Toothbrush and paste
• Extra keys for you house

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Waterproof cases are very useful
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This may be the only source of light for several
weeks
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A Leatherman comes in very handy
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Dont forget the can opener
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Lavender ID Cards
http//kcercoalition.com/pdf/IDcard92508.pdf
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Lavender ID Cards

• Dialysis teammates should assist patients in
  completing the other sections of this card.
• It is not a substitute for medical records. But
  is simply to help the local rescue teams find out
  contact information.
• Dialysis facilities should assure that the local
  rescue authorities also are aware.
• This will be invaluable if a dialysis unit has
  been closed due to either long term or temporary
  damage.

• This is a simple four part card that the patient
  can carry with them at all times. They can
  complete their network name, and number.
• It immediately shows EMS and rescue personnel
  they are on dialysis and thus need special
  attention.
• These cards should be distributed through
  dialysis facilities at the time the disaster is
  being discussed.

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THE BAND
Great 60s rock group, but not what we have in mind
Source YouTube
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Get Banded

• OTHER BAND COLORS
• DNR
• Texas hospitals were encouraged to adopt specific
  red-purple bands with labeling DNR in addition
  to writing and documenting this in the chart.
  Patient families must understand this and if the
  order is rescinded, the band need to be removed.
  Even with the wristband, the staff should look in
  the chart
• FALLS
• The color yellow with Fall Risk on a wrist band
  indicates caution! much as with a traffic
  light. The American National Standards Institute,
  ANSI uses this color to indicate the potential
  to trip or fall. Patients who have a history of
  dizziness, balance, unsteadiness, falling or
  confusion should be wearing this band. Older
  adults have a five time likelyhood of falling,
  and 20 to 30 percent suffer severe injuries and
  the risk of premature death. The total cost of
  fall related injuries to people over 65 is 27
  billion dollars based on extrapolition from 1994
  data. This projects to 43.8 billion dollars by
  2020. Hip fracture admissions were 338,000 in
  1999.
• ALLERGIES
• A wrist band with the word ALLERGY is
  encouraged in Texas hospitals. This coincides
  with ANSI, the American National Standards
  Institute which uses red to indicate danger! or
  stop! The red band should alert a caregiver to
  double-check if a patient has a medication, food
  or treatment allergy. This should help encourage
  safety and reduce errors. The allergies should
  also be written in the medical record. They
  should not be written on the wrist band because
  of legibility listed, assumption that the wrist
  band information is complete when it may not be,
  and that it would encourage multiple sources of
  information. The medical record must be the
  clearing house for all information regarding the
  patient regardless of where it comes from.

• WRIST BAND STANDARDS
• Identifying patients who are at risk and are not
  independent is the first strategy in preparing
  for disasters. Failure to rescue is thus
  classified with fall, allergy and other safety
  risks. Communication is critical in dealing with
  those who cannot assist themselves. Color coding
  is simple and allows for quick identification.
• Wristbands should be pre-printed with text that
  describes what the band means. This reinforces
  the bands meaning and reduces confusion. Other
  bands such as LIVESTRONG should not be worn
  during a disaster or hospitalization. Also
  patient identification bands that display the
  hospital number should always be removed when the
  patient leaves to another facility. Family
  members should be educated and part of the
  process. The color coding should be used
  throughout the system, and staff must always
  verify the meaning of the band during
  communication, transfer or hand-offs to other
  personnel. Bands for other causes should be
  eliminated.

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Get Banded

• RFID Placed on wrist of evacuees
• The emergency alert band in Texas is designed to
  track patients who have been evacuated during a
  crisis. This coordinates with the Texas ESRD
  EMERGENCY COALITION AND THE NETWORKgt The bands
  should not be removed.
• RFID bands with a printed image of the State of
  Texas seal and imbedded RFID technology help
  identify patients, who can be quickly scanned
  with a mobile device that allows for validation
  for registered individuals against other
  databases for cross referencing. This expedites
  the accurate movement of people, increases
  security, and allows proper allocation of
  resources. Families should NOT remove these RFID
  bands

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Are you R.E.A.D.Y.

• R is for Rx
• E is for ER in emergency
• A access (phone numbers)
• D diet and liquids
• Y is for YOU (make plans to be with
  someone)

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YOU

• Have your patients designate an out-of-area
  contact person and look up the dialysis units in
  that area on http//dialysisunits.com
• Important documents need to be duplicated put
  in a safety deposit box or with someone you
  trust, or scan and put online (googlehealth,aakp
  myhealth, http//www.me.com)
• Inventory/photograph your valuables and upload to
  http//www.me.com or put in a safety deposit box

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Have a meeting place

• If a disaster strikes family members should have
  a well-defined place to meet such as the school
  year. This will prevent people entering a harmful
  environment when one is lost.
• During a community disaster, all electrical
  services including cell phones and computers
  will be non-functional. Thus setting this up in
  advance is vital.

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The school is a great meeting place.
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Resources
There are multiple web sites which have
information about disasters. I have listed a few
here. It is wise to visit these and research the
information available in making your plans.
There are also available pre-done lists of forms
needed by units and or patients.

• esrdnetwork.org/
• Important liaison for disasters
• Coordination of care located in Dallas
• kcercoalation.com
• Specifically designed for disaster preparedness
  in ESRD patients
• Very valuable resource and organization
• www.texasemergencyesrd.org/
• TEEC
• Constant emergency updates
• www.kidneydisasters.org
• Servers not in Houston
• News aggregator
• www.dialysisunits.com
• Updated list of dialysis units
• Find responders and closed units
• www.kidney.org/help
• NKF
• Planning for natural disasters and other types of
  emergencies

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Network 14

• Our network web site is very useful
• http//esrdnetwork.org

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KCER COALITION

• Kidney Community Emergency Response Coalition
• Formed after Hurricane Katrina 2006 by
  representatives 50 government organizations,
  organizations and private companies
• SUMMIT Powerpoint
• http//kcercoalition.com/pdf/2008SummitSlidesPDF.p
  df
• 2 CJASN articles outline recommendation
• Website http//kcercoalition.com

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KCER COALITION
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KCER COALITION

• KCER PATIENT VIDEO
• FOR PATIENTS
• DEMONSTRATES WHAT THEY NEED TO KNOW ABOUT A
  DISASTER
• KCER PATIENT SERVICES TEAM
• MUCH OF IT WILL BE FILMED IN HOUSTON

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Texas Emergency ESRD Coalition
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Dialysisunits.com
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Dialysisunits.com

• Established between the Forum of ESRD Networks
  and the Nephron Information Center in 1996 by
  Alex Rosenblum, Ida Sarsitis and Steve Fadem.
• Main resource for dialysis facilities feeds off
  CMS database and updated monthly
• Links into Dialysis Facility Compare and Google
  maps.
• In the event of a unit closure, the ESRD Network
  coordinator updates the database.
• The website is designed to broadcast over mobile
  devices as hh.nephron.com so that one can access
  it from an automobile while evacuating.

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Clinic operations tracking tool

• Dialysis Units in the USA was started in 1996 by
  the Nephron Information Center at the request of
  ESRD Network 14 and the Forum of ESRD Networks.
  During Hurricane Katrina, a field in the software
  program was added by Brian Rosenthal to enable
  executive directors and CMS to list facilities
  and sort by facilities that were closed. This
  was extensively tested and refined as part of
  KCER, under the leadership of Network 14
  executive director Glenda Harbert. It has been in
  use ever since. During Hurricane Ike, a record
  number of dialysis facilities were listed as
  closed in Houston and Galveston. The large
  dialysis organizations deserve much credit for
  coordinating the information on this simple, but
  highly useful Web application. Since Katrina,
  dialysisunits.com has been modified to also allow
  access to the information on hand held devices
  and cell phones so patients, staff and responders
  could access this information from cars
  (hh.nephron.com)  kidneydisasters.com also
  provides updated hurricane tracking information
  and embeds NOAA maps. It also includes key phone
  numbers. Its servers are not in the Houston area.

Source NephrOnline, Hurricane Ike What we
learned 12/11/200 Stephen Z. Fadem, M.D.
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http//72hours.org
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By declaring a state of emergency, several
benefits were offered to the residence of coastal
Texas and Louisiana while we recovered. When the
Secretary of HHS declared a public health
emergency, certain waivers for survey and
certification rules went into effect.
Source http//www.cms.hhs.gov/SurveyCertEmergPrep
/Downloads/AllHazardsFAQs.pdf
64
Mutual Assistance
65
Mutual Assistance
Centerpoint Energy is a Texas-based holding
company that provides energy to five million
customers in a six-state area. It has 8,600
employees. Prior to the storm it warned that
power could be out for up to two weeks as a
result of trees and branches falling on power
lines. Customers were advised to turn their main
circuit breakers off. Centerpoint is part of a
nation-wide mutual assistance program that
redirects manpower to disaster sites around the
nation. Over 7,000 emergency trimmers and linemen
from 36 states came to Houston to help many
would did not see their homes for up to five
weeks, as Ike followed Hurricane Gustav, which
hit the Gulf Coast on Sept. 1.Taking heed, DaVita
arranged for several generators to be on standby
and ready for delivery once the storm passed. On
September 12, as the storm surged across
Galveston, Centerpoint customers lost power. By
11 am the following day, 2.1 million of the 2.6
million area customers were without power, mainly
because of destruction to power lines. Luckily,
service to the Texas Medical Center was
maintained. Water treatment services were also
maintained, although Houston was under a
transient bottled-water alert. By Sunday,
September 14, mutual assistance crews started
working around the clock, first assessing damage,
removing fallen trees and limbs from power lines.
Next, the lines and transformers were inspected
and made hot. In some neighborhoods, the damage
could be traced to power stations, which were
destroyed by high wind gusts, and had to be
rebuilt.It is estimated that the
Houston/Galveston area will generate 15 million
cubic yards of debris, and require as much as 40
billion to restore the two cities. The storm
surge and heavy flooding extensively damaged
Galveston. While sewer service has been restored,
water is not potable and electrical services are
down. There will be much in the way of debris
removal and rebuilding. Dialysis patients were
transferred to facilities on the mainland while
the repairs to dialysis facilities, and their
homes were underway.
Source NephrOnline, Hurricane Ike What we
learned 12/11/200 Stephen Z. Fadem, M.D
66
Mutual Assistance
Power companies across the nation have developed
collaborative agreements to help each other in
the event of a catastrophe, so must the renal
community. Ongoing efforts to do this should be
encouraged. When catastrophe shifts the balance
of patients from one point to another, the load
related to personnel, equipment, transportation
and other resources must to accommodate newly
created demands. This must cross corporate lines,
requiring collaborative agreements between large
dialysis organizations. This is necessary not
only to develop and implement plans and mock
scenarios, but to share patient information.
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Have a backup plan
How can a tree that has survived storms for the
past fifty years fall across our path with this
one? We will never know, but should it happen,
need an alternate route. Each storm brings a new
surprise. Ike taught us the value of coordinating
with power companies, the need to balance nurses,
resources and patients and that hurricanes have
several faces flooding, electrical outages,
cell phone outages, traffic jams are all
co-morbidities we must now anticipate. We
learned to evacuate early, triage patients in
advance to other units, and try to avoid shelters
or emergency rooms when possible.
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Disasters have been around since the universe
began, and our task is to survive them. Someday
we will have another opportunity to test our
resourcefulness in dealing with a major disaster
The End