Defining a Disaster

Disasters are commonly categorized by their origin, such as natural, man-made, technological, or human conflict. Many definitions of disaster are found in the literature. The World Health Organization (WHO) defines a disaster as “a serious disruption of the functioning of a community or a society involving widespread human, material, economic, or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using its own resources.”¹

The broad scope of the WHO definition includes disasters that cause mass casualties and those that do not involve human injury or illness. A definition of disaster often used by health care systems is “the number of patients presenting, during a given time, that exceed the capacity of an emergency department (ED)/casualty department to provide care and as such, will require additional allocation of human and durable resources from outside the ED.”¹ This definition excludes disasters that do not have surviving patients presenting to the emergency department. Many incidences, such as plane crashes, leave few or no survivors. Others, such as technological disasters, often do not include human injury or illness in other settings, but within health care systems these disasters affect patients dependent on technology for survival (those on ventilators or intravenous pump machines). Though most disasters involving technology, such as large power grid failures or computer system failures, do not directly cause injury or illness, these disasters can have serious indirect effects on human lives, typically affecting those most dependent on the technology for survival.

Disaster Nursing

Nursing during a disaster often focuses on the care of patients experiencing physical injury, illness, and emotional response to the event. To care for casualties following a disaster, nurses and health care providers must have an understanding of elements of disaster management such as mitigation, planning, response, and recovery.

Not all disaster incidents involve patients arriving at local emergency departments or casualty departments. Catastrophic incidents may affect the infrastructure of the hospital or community in which the hospital is located. These nonpatient generating disaster incidents include loss of computer system infrastructure, loss of electrical or water supply to a hospital, or loss of telephone systems within the hospital. With the goal of adopting digital medical records in the United States by 2016 and the global trend to make all hospital documentation electronic, loss of computer system function can have a stressful and often negative impact on hospitals and potentially on patient care.

Patient-generating disasters are often of a natural origin (e.g., tornadoes, hurricanes, and floods), whereas others are man-made incidents (e.g., the September 11, 2001 terrorist attacks in New York City and Washington, D.C.; the 2002 bombings at a nightclub in Bali; and the 2004 train bombings in Madrid). These man-made disasters had a direct impact on health care systems, often to the point of saturating receiving facilities closest to the incident.

Fundamentals of nursing during a disaster, mass casualty incident (MCI), special event, or even those disasters originating from error, natural causes, or man’s infliction of terror, are essentially the same. Time is an important factor as lives can be saved by quick triage and decision making that allow rapid treatment for the most critically ill or injured patients. The principle of doing the most good for the most number of casualties often with limited resources is inherent to nursing during an MCI, disaster, or large-scale special event.

Emergency Management

Emergencies can be threats to any health care organization. Since 2008 The Joint Commission has required hospitals to meet the new Emergency Management (EM) standards, which are separate and distinct from the Environment of Care standards.² These new EM standards are organized around the four phases of EM: mitigation, preparedness, response, and recovery (see Fig. 3-1).

Fig. 3-1 Four phases of Emergency Management.

Emergency Management aims to reduce or avoid potential losses, including loss of life and property, from potential or real disaster. The four phases of EM illustrate the ongoing process by which health care systems plan for and reduce the impact of a disaster, react during and immediately following a disaster, and take steps to recover after a disaster has occurred. Appropriate actions at all points in the cycle lead to:

• Greater preparedness

• Better warnings

• Reduced vulnerability

• Prevention of disasters (see Table 3-1)

TABLE 3-1 FOUR PHASES OF EMERGENCY MANAGEMENT WITH ACTIONS

Mitigation Take places before and after an emergency occurs	Activities designed to either prevent the occurrence of an emergency or minimize potentially adverse effects of an emergency, including zoning and building code ordinances and enforcement of land use regulations. Action: Buying flood and fire insurance for the home, placing security cameras around the hospital, and installing hurricane shutters are examples of mitigation activities.
Preparedness Takes place before an emergency occurs	Activities, programs, and systems that exist prior to an emergency and are used to support and enhance response to an emergency or disaster. Public education, planning, training, and exercising are among the activities conducted under this phase. Action: Evacuation plans and stocking food and water are both examples of preparedness.
Response Takes place during an emergency	Activities and programs designed to address the immediate effects of an emergency or disaster, to help reduce casualties and damage, and to speed recovery. Coordination, warning, evacuation, and mass care are examples of response. Action: Seeking shelter from a tornado or turning off gas valves during an earthquake are both response activities.
Recovery Takes place after an emergency occurs	Activities involving restoring systems to normal. Recovery actions are taken to assess damage and return vital life support systems to minimum operating standards; long-term recovery may continue for many years. Action: Obtaining financial assistance to help pay for repairs or removing debris are recovery activities.

The complete disaster management cycle includes shaping health care facility policies and plans that either modify the causes of disasters or mitigate their effects on people, property, and hospital and community infrastructure. The mitigation and preparedness phases occur as disaster management improvements are made in anticipation of a disaster event. Developmental considerations play a key role in contributing to the mitigation and preparation of a health care system to effectively confront a disaster. The four EM phases do not occur in isolation or in this precise order. Often phases of the cycle overlap and the length of each phase greatly depends on the severity of the disaster. Because the four phases of EM are so crucial, this chapter will address each one in depth.

Mitigation

Within hospitals and health care facilities, mitigation implies the steps taken to prevent all possible hazards that may lead to a disaster. The mitigation phase of EM is unique because it focuses on long-term tasks that are effective in reducing or eliminating any risk of a disaster occurring. Obviously not all risks can be eliminated—hurricanes, tornadoes, and other disasters from natural causes are examples. However, when implemented, mitigation strategies minimize the harmful effects of these disasters on the health care facility and its operation. In hurricane-prone areas, for example, hospitals can install shutters to minimize the wind effect on the building. In flood-prone areas, a dam can be built to prevent or minimize the degree of flooding. Another mitigation strategy for hospitals in a flood-prone area is to elevate any critical infrastructure such as energy units (electrical), oxygen farms, or generators. Figure 3-2 is an example of such a mitigation plan.

Fig. 3-2 Example of Indian River County mitigation strategy.

(From Indian River County Florida Board of County Commissioners. [2009, December]. Local mitigation strategy project prioritization list. Retrieved from http://www.ircgov.com/Boards/LMS/2010_Project_List.pdf)

The first step in mitigation is to identify risks. The Joint Commission standards EM.01.01.01 and EM.03.01.01 discuss the need for a hospital to evaluate potential emergencies that could affect demand for the hospital’s services or its ability to provide those services and the effectiveness of its emergency management planning activities aimed at managing those emergencies.² This includes an annual review of hospital risks, hazards, and potential emergencies as defined in a hazard vulnerability analysis.

Hazard Vulnerability Analysis

A hazard vulnerability analysis (HVA) is a systematic approach to:

• Identify all hazards that may affect an organization and its community

• Assess the risk and probability of hazard occurrence

• Determine the consequence for the organization associated with each hazard

• Analyze the findings to create a prioritized comparison of hazard vulnerabilities

Table 3-2 lists potential threats for HVA consideration.

TABLE 3-2 POTENTIAL THREATS REQUIRING AN EMERGENCY MANAGEMENT PLAN AND RESPONSE

THREATS FROM NATURAL CAUSES	MAN-MADE THREATS	TERRORIST THREATS
Pandemic flu	Explosions	Conventional weapons
Hurricanes	Hazardous materials	Explosive or incendiary devices
Floods	Transportation accidents or incidents	Biological or chemical devices
Fire	Assaults, threats, or acts of violence	Radiological exposure devices
Tornadoes	Arson	Cyberterrorism
Ice storms	Power grid failure	Weapons of mass destruction