Transcript Disaster Preparedness In California Skilled Nursing and Long Term

Nursing Homes:
Part of the Solution in
Community
Preparedness
EM Summit March, 2009
Jocelyn Montgomery, RN, PHN
California Association of Health Facilities
Disaster Preparedness Program
What is
Long
Term
Care?
Long Term Care Facility
• Refers to any of a range of institutions that
provide health care to people who are
unable to manage independently in the
community
• Facilities may provide short and long-term
rehabilitative services as well as chronic
health care management
www.longtermcareliving.com/glossary
Wide Range of Facilities
in Long Term Care
• It can consist of:
– Care in the home by family members who are
assisted with voluntary or employed help
– Adult day health care
– Care in assisted living facilities
– Care in skilled nursing facilities
– Care in other types of residential facilities
www.longtermcareliving.com/glossary
Wide Range of Recipients in
Long Term Care
• It can include people who are:
– Pediatric, elderly, in between
– ambulatory
– non ambulatory
– cognitively intact
– cognitively impaired
– minimal assistance
– completely dependant for all activities of daily living
And have special medical and/or behavioral needs
Skilled Nursing Facility Defined
“Skilled nursing facility" is defined as an
institution (or a distinct part of an institution)
which is primarily engaged in providing skilled
nursing care and related services for residents
who require medical or nursing care, or
rehabilitation services for the rehabilitation of
injured, disabled, or sick persons, and is not
primarily for the care and treatment of mental
diseases; …
§§1819(a) and 1919(a) of the Social Security Act
Snapshot of Nation’s SNFs
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Approximately 16,000 SNFs
1,730,000 licensed beds
917,000 nursing staff
122,400 RNs
192,100 LPNs
608,900 CNAs
12,500 NAs/Orderlies
CDC National Center for Health Statistics 2006/2007 data
Snapshot of SNF Residents
• 1,492,200 living in skilled nursing homes on
any given day.
• The vast majority of these people are:
• 75 or older
• Female
• White
• Stay less than 3 months
Snapshot of SNF Residents
• Disease prevalence
very high
• 61% have mental &/or
cognitive conditions
• 41% do not walk
• Only 18% walk without
help or supervision
Kaiser Commission on Medicaid and the Uninsured 2007
SNF Disaster Capabilities
• A critical component of the healthcare
system
• Experts in caring for medically fragile
populations
• Bed capacity
• Back up power
• Medications
• Emergency Supplies
Federal Regulation
Requirements
• CFR 483.75 (m) disaster
and emergency
preparedness
• F517 (1)the facility must
have detailed written
plans and procedures
to meet all potential
emergencies and
disasters, such as fire,
severe weather, and
missing residents.
Federal Regulation
Requirements
• CFR 483.75 (m) disaster and
emergency preparedness
– F518 (2) The facility must train
all employees in emergency
procedures when they begin to
work in the facility, periodically
review the procedures with
existing staff, and carry out
unannounced staff drills using
those procedures
Skilled Nursing Facilities as
Resource?
YES…
BUT…
SNF Disaster Challenges
• SNFs serve the medically fragile, who may
be more severely impacted by disasters
• Very little physician presence
• High staff turnover
• Scare resources for training or equipment
• Typically not included in healthcare
preparedness community coalitions
SNF Disaster Needs
• More involvement with local planning
efforts
• Stronger facility emergency operation
plans, particularly from the “walls out”
• Assistance to prepare as a partner in
response
Nursing Homes During
Katrina
Nursing Homes During
Katrina
• All studied Gulf State nursing homes (20) met
the federal requirements on their most recent
state survey
• All experienced problems, whether they
evacuated or sheltered in place
• Plans were often missing several planning
elements recommended by experts
• Plans were not up to date
• Administrators not always familiar with plans
Nursing Homes During
Katrina
Evacuation Issues:
– Instructions for evacuating to an alternate site
– Guidance for deciding whether to evacuate or
shelter in place
– Information about the specific needs of
residents (to allow staff to modify plans
according to residents’ needs)
– Plans for reentry of facility
Nursing Homes During
Katrina
Sheltering in Place Issues:
– Problems with staffing
– Uncertainty of access to community resources
– Shortages of supplies narrowly averted
– Power disruptions (2 hours—4 weeks)
– Generators taxed (A/C in high temperatures;
generators only supported lights and fans)
– Psychological stress on residents
Nursing Homes During
Katrina
Findings:
• Lack of collaboration between state & local
emergency entities and nursing homes
– Review of plans and prior collaboration can
build better plans, and result in better
emergency management & access to
resources
HHS. Nursing Home Emergency Preparedness & Response During
Recent Hurricanes. Aug. 2006.
Southern California 2007
Largest Evacuation (CA History)
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Approximately 515, 000 people evacuated
Over 2,200 medical patients evacuated
14 Skilled Nursing Facilities
5 Intermediate Care Facilities (MR)
1 Acute Psychiatric Facility
3 General Acute Care Hospitals
How Did LTC Do?
• No structures lost
• No disaster – related deaths
• Displace residents received
excellent care at other
facilities and shelters
• Staff reported to work
Many not knowing whether
or not their house were
standing
Lessons Learned During Fire Storm
NEED:
• Centralized location to coordinate special needs
response operations, patient and bed tracking.
• Patient identification bands with critical medical
information.
• Staff identification that enable them to return to
facilities.
• LTC evacuation plans that adequately address
transport of patients to other facilities.
• Criteria for approval to repatriate facility
CAHF NEEDS ASSESSMENT
• Needs Assessment
– Evacuation
– Sheltering in place
– Pandemic
– Power failure
• Self-sufficiency and self-reliance
Methods
• Survey of California LTC facilities
• Collected via Survey Monkey, July – October 2008
• Sample size: 115 completed, 134 total responses
– Convenience sample, self-reporting
• Sample probably represents the “best prepared” facilities
Type of facility
SNF
Sub Acute
8%
4%
3%
4%
2%
Intermediate care facility (ICF)
ICF/Developmentally disabled (DD)
ICF/DD/Habilitative
ICF/DD/Nursing
79%
Overview of responses
• Responses completed by:
– Facility administrator (71.8%)
– Director of nursing (13.6%)
– Director of staff development (12.7%)
Percent of facilities
• Facility size – well distributed
40
30
Licensed beds
20
Average daily census
10
0
1-6
7 - 15
16 - 59
60 - 99
100 - 199
Num ber of beds
200 - 299
300+
Readiness for evacuation
• Evacuation includes:
– Receiving residents
– Sending residents
– Agreements with “like” facilities
• Within emergency operations plan (EOPs):
– 99.1% facilities address evacuation
– 87.9% address coordination with “like” facilities
– 80.3% included processes for sharing residents’ information
with other facilities and external/public agencies
• Evacuation planning with local community partners
ranked second as a priority for next year
Sending residents/patients
• Readiness of facilities to evacuate within 1 hour:
– Food ready to go: 87.4%
– Water ready to go: 82.4%
– Essential medical supplies/medication ready to go:
84.9%
– Critical health info for residents ready to go: 87.4%
• Planned evacuation meals for residents: 74.6%
• Planned meals for staff: 44.9%
Transportation preparedness
• Facilities with transportation vendors or
ownership of vehicles for use in an
evacuation: 47.9%
– Of these, 44.7% have discussed their
vendors’ business continuity plan and priority
of assistance
• 43.7% do not have readily available
means to evacuate residents
– And are dependent on external emergency
agencies
Receiving residents/patients
• Does the EOP address receiving patients?
– 69.7% did
– 19.7% did not
– 10.6% didn’t know
• Specific procedures for accepting
residents from like facilities:
– 70.9% did
– 20.5% did not (8.5% did not know)
Managing unsolicited clinical
help
• Lack preparedness to handle clinical
volunteer
• Most facilities did not have procedures to
manage unsolicited clinical help
• Most facilities did not have procedures to
request and receive volunteer health
professionals from the county:
Readiness for sheltering in place
Performance target: > 72 hours’ supplies on hand
Most facilities in survey prepared – in some way – to SIP
However, adequate pharmaceuticals: only 76.7%
Facilities with no water stored: 6% either had no water
for staff or residents
Days of potable water stored
Percent of facilities
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•
•
•
80
60
Water for residents
40
Water for staff
20
0
None
1
2
3
Days
4
5
>5
Sheltering the staff in place
•
Adequate water (72+ hrs) for staff: 89.0% of facilities
Adequate food for staff: 88.1%
Extra bed linens for staff: 71.8%
Adequate extra cots, mattresses, or roll-away beds for staff: 25.4%
Most facilities have at least some supplies, even if they fall below the
72 hour target
But…this also means 11% don’t have adequate water, 12% don’t have
adequate food, etc.
Supplies for staff to shelter in place for 72 hours
Percentage
•
•
•
•
•
100
80
60
40
20
0
Yes
No
Some, but not enough
Don't know
Food
Potable
water
Bed
linens
Type of supply
Cots
Power and utilities
• Automatic gas shutoff valves in 49.2%;
facilities without gas shutoff values 42.4%
(7.6% didn’t know)
• Power failure addressed in EOP: 85.3% of
facilities
• Facilities with stand-by/emergency
generator capability 89.8%
Percentage of facilities
Services tied to generator power
100
90
80
70
60
50
40
30
20
10
0
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45
40
35
30
25
20
15
10
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0
Le
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Percent of facilities
Generator time using circuits identified (see previous graphic)
Percentage of facilities
Alternate forms of communication
100
90
80
70
60
50
40
30
20
10
0
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Internet-connected computers
• Most facilities: at least 5 computers
• Most facilities (> 94.6%) used their computers for web
access and email, facility computers played a key role in
clinical care:
• Residents had internet access in 18.4% of facilities.
Percent of facilities
Internet-connected computers
40
30
Com puters w ith
internet access
20
10
0
None
1-5
6 - 10
11 - 20
21 - 30
> 30
Security
• Lacking funding, lacking dedicated resources
• Most facilities’ staff not required to wear photo
identification:
• Most facilities (69.9%) did not have security staff
• Facilities with procedures for locking down all exterior
doors without help from external agencies: 54.7%
• Several facilities identified the use of surveillance
systems (alarms) and/or security cameras as security
mechanisms
Emergency operations plans
(EOP)
• Hazard and Vulnerability Analysis
• 22.2% completed HVA within last 5 years
– 41% had not
– 36.8% didn’t know
• EOPs covered:
–
–
–
–
–
Evacuation planning - 99.1%
Sheltering in place - 96.6%
Command and control - 95.7%
Triage of casualties - 86.2%
Contingency of power failure - 85.3%
Local planning aspects
addressed in EOPs
Yes
No
Don't know
100
90
Percent of facilities
80
70
60
50
40
30
20
10
0
Hospitals
Em ergency
planners
Com m unity or faith
based groups
Coordination with local entities
"Like" facilities
Engagement in local planning
• Local surge planning
– Facilities participating - 48.3%
– Not participating - 34.7%
– 16.9% didn’t know
• Receiving funds or supplies from local
health/emergency services agency
– Did receive funds/supplies - 6.8%
– Did not - 82.9%
– 10.3% didn’t know
• EOPs reviewed by local emergency planning
officials:
– 39.1% of facilities
– 47% had not been reviewed locally
– 13.9% didn’t know
Incident command systems
Use of HICS for emergency
operations
Don't
know
27%
Yes
31%
No
42%
Pandemic influenza preparedness
• A general lack of preparedness
• Isolation/reverse ventilation rooms:
– Facilities with: 16%
– With out: 82% did not (2% didn’t know)
• Infectious disease emergencies addressed in
EOPs:
– 38.3% addressed quarantine
– 37.1% addressed configuration of facility space for
isolation or quarantine during an epidemic; and,
– 27.4% addressed storage of remains following a
mass casualty event
Infectious disease preparedness
as addressed in EOPs
Yes
No
Don't know
60
Percent of facilities
50
40
30
20
10
0
Isolation of infected
patients
Quarantine
Reconfiguration of
space for quarantine
Top 5 ranked priorities for the
future
1. Training staff in emergency procedures
2. Evacuation planning, particularly with
external partners
3. Implementing an incident command system
for use during emergencies
4. Diagnosis and treatment of residents and
staff with potentially infectious diseases
5. Formalizing MOUs with like facilities;
arrangements with vendors/service providers
Response Community Working
with LTC Providers
• Understand the unique position that LTC is in,
BOTH as a resource and as a group that may
have needs
• Actively include LTC in your disaster-related
workgroups and planning activities (example:
pandemic planning)
• Accept invitations from the LTC community to
work together (meetings, planning)
• Consider the challenges they face
California SNFs
Some Positive Practices
CAHF Disaster Preparedness
Program
• Increase disaster readiness
of individual long term care
facilities (LTC)
• Promote integration and
collaboration between LTC
providers and
– Other providers
– Other healthcare partners
– Emergency response
planners
– State
– Regional
– Local levels
http://www.cahf.org/public/dpp
Pandemic Influenza
Workbook for Long Term
Care
Available on website
Released in Sept 2007
WHO Pandemic Stages
Containment Strategies
Non-Pharmaceutical
Containment: Self Isolation
If you have the flu,
or if you think you might have the flu,
or if you have been exposed to someone
who has the flu…
PLEASE STAY OUT!
If you MUST enter, please!!!
wear a mask,
wash your hands frequently,
avoid coughing/sneezing near anyone else,
And leave as soon as possible!!!
Quarantine Within Your Facility
• If a definite exposure has occurred in a limited
part of the facility, these people should be kept
apart from the rest of the population as
effectively as possible
– Cohort sick residents
– Quarantine roommates who would also have been
exposed to the infected individuals
Sustainment Strategies
• Broad impact over
geographies, ages,
workforces
• Prolonged over
weeks/months
• Resources will be
decreased
• Demand for care will be
increased
PI Annex to Disaster Plan
• Build on the existing plan:
Disasters and Infectious Disease Outbreaks
• Add sustainability over weeks/months
• Staffing strategies
• Plan for higher acuity residents due to
an inability to transfer to acute care
• Management of deceased
Start Stocking Up Now
Types of Supplies to Stockpile
• Disaster supplies for all hazards (including food,
water, etc.)
• Personal Protective Equipment (PPE)
Simple Oral Rehydration
• Rehydration supplies
Solution
• Infection control supplies 1 TSP salt
4 TBSP sugar
• Respiratory care supplies 8 Cups of clean drinking or
boiled water and then cooled
• Mortuary supplies
• OTC medications and Rx meds (antivirals) as
allowable under the regs
Emergency Staffing Strategies
• Prepare for “worst case” 50 %
absenteeism
• Cross Training in essential services
– Resident Care
– Food Service
– Housekeeping
– Laundry
– Essential Administrative Procedures
Shift to “sufficiency of care” approach
Facility Security
• Protection of supplies may be important
• Consider assigning security personnel
during high risk times
• Control access to facility
• Control access to supplies
• Self protection training for staff
• Deliveries of supplies be protected
Current DPP Projects
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Advocacy and Collaboration
Respiratory Protection Initiative
Needs Assessment
Planning Summits
Education and Outreach
Table Top Exercise Tool
Website
www.cahf.org/public/dpp
San Diego County
Collaboration Model
Disaster Area Coordinators
San Joaquin County Model
Base Control Hospital
Alameda County Model
It takes all the healthcare assets
working together
So Lets Work Together!
Jocelyn Montgomery RN
Director of Clinical Affairs
California Health Care Association
[email protected]